SRPS PS - Plastic Surgery Internal

SRPS Volume 10, Issue 25, 2009
In the event that the thumb or little finger is
involved with tenosynovitis, the infection can extend
proximally to involve either the ulnar or radial bursa.
The two bursae communicate through the space of
Parona, deep to the flexor tendons in the distal
forearm. A “horseshoe” abscess can form where a
flexor tenosynovitis, beginning in either the thumb or
little finger flexor sheath, spreads proximally to the
space of Parona and then passes distally down either
the little finger or thumb flexor tendon sheath. Phillips
et al., 77 however, showed that the little finger flexor
synovial sheath often ends at the level of the A1 pulley,
so that little finger tenosynovitis usually can be
managed by drainage of the finger alone. In instances
in which an infection extends proximally, closed
catheter drainage is indicated. The catheter is directed
proximally from the incision at the level of the A1
pulley. A counter incision is then made just proximal to
the transverse wrist crease, where a drain is placed in
the bursa. This system is managed in a similar fashion
to the digital system. Again, if the patient does not
respond to this treatment, open drainage of the bursae
is necessary.
Deep Space Infection
A variety of “spaces” have been described in the hand.
In reality, the spaces are potential and become
significant only when infected, as they become
loculations of purulent material. They include the
thenar space, the midpalmar space, the subtendinous
space, also known by the eponym Parona space, the
hypothenar space, the dorsal subcutaneous space, the
dorsal subaponeurotic space, and the interdigital web
spaces. 78 The spaces often are confused with the
compartments of the hand, which are the four dorsal
interossei, three volar interossei, thenar, hypothenar,
and adductor pollicis compartments.
Infection in the spaces begins most frequently with
a penetrating injury, the most commonly identified
isolate being S. aureus. An antistaphylococcal agent can
be used for initial antibiotic therapy unless gram stain
at the time of drainage suggests another organism. As
clearly described in the pre-antibiotic era by Kanavel, 69
the key to treatment of deep space infections is precise
drainage of the abscess, guided by knowledge and
respect for the surrounding and involved structures.
8
The most important deep spaces of the hand are
the midpalmar space and the thenar space (Fig. 8). 21
Thenar space infections usually are characterized by
the thumb being held in an abducted position, with
pain over the adductor muscles and pain on extension
or attempted opposition of the thumb. Thenar space
infection is the only hand infection with which the
thumb is not adducted. Drainage of the abscesses must
not only respect the proximity of neurovascular
structures, primarily the radial bundle to the index
finger and the ulnar bundle to the thumb, but also
must prevent scarring across the thumb-index web.
Figure 8. Deep spaces of the hand. (Reprinted with permission
from Brown and Young. 21 )
The midpalmar space, exclusive of the flexor
tendon sheaths, allows free spread of infection along
fascial planes to deeper areas in the hand. Treatment
consists of incision and drainage with catheter
irrigation for 2 to 3 days. 78
Osteomyelitis
Osteomyelitis of the bony structures of the hand is a
relatively infrequent infection. 79 Osteomyelitis can
present as a spontaneous bone infection, usually by
hematogenous seeding from a distant source. The most
likely pathogens are Staphylococcus and Streptococcus
species and, in young children, Haemophilus species.
Osteomyelitis presents as a localized focus of
erythema, pain, and swelling along the course of one
of the long bones of the hand. If the infection does not
show clinical signs of improvement within 48 hours of
commencing intravenously administered antibiotic
treatment, bone biopsy should be performed to obtain