SRPS PS - Plastic Surgery Internal

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tendon represents the proximal limit of excision. Reardon et al. 15 recommend that excision of the nail matrix should be rectangular, extending to the midlateral lines. Microvascular nail transfer is the definitive method for replacing the entire nail matrix but is a major procedure for what is as much an aesthetic as a functional outcome. 16,17 Deformities Posttraumatic retraction and deformity of the eponychial fold can occur after lacerations or burns. One-stage flap options are possible for correction of this problem. 18,19 In cases in which the nail fold is not properly stented open, the patient might develop a synechia and skin pterygium, which can lead to secondary nail deformities. Prevention by appropriate nail fold splinting is recommended to avoid the problem. INFECTIONS Sixty percent of all hand infections are the result of trauma, 30% result from human bites, and 10% result SRPS Volume 10, Issue 25, 2009 from animal bites. 20 Hand infections account for approximately 20% of all admissions to hand surgery units and often are accorded a lower level of significance than warranted. When the infection is treated appropriately, the patient returns to optimal function in a short time. If the infection is inadequately treated, the patient is resigned to pain, stiffness, and disability. Amputation is sometimes required in extreme cases. Microbes and Antibiotics The most frequent pathogen involved in hand infections is Staphylococcus aureus, accounting for 50% to 80% of all isolates. 20–25 The microbes, unfortunately, are likely to be resistant, as shown in multiple studies. 26,27 However, specific aspects of the history and/or physical examination findings can implicate other organisms as the inciting agent. Careful attention to the aspects and findings allows the physician to make an appropriate choice of initial antibiotic(s) to cover all reasonable pathogens (Table 1). Indiscriminate use of excessively broad-spectrum Table 1 Empiric Antibiotic Treatment for Some Common Hand Infections24 Infection Antibiotic Likely Organisms Cellulitis/lymphangitis First-generation cephalosporin or antistaphylococcal penicillin Paronychium/felon Dicloxacillin or fi rst-generation cephalosporin Flexor tenosynovitis β-Lactamase inhibitor or fi rst-generation cephalosporin and penicillin; consider ceftriaxone Deep space infection β-Lactamase inhibitor or fi rst-generation cephalosporin and penicillin Human bite wound β-Lactamase inhibitor or fi rst-generation cephalosporin and penicillin Dog or cat bite wound β-Lactamase inhibitor or fi rst-generation cephalosporin and penicillin Streptococcus pyrogenes, S. aureus S. aureus, anaerobes S. aureus, streptococci, anaerobes; Neisseria gonorrhoeae S. aureus, streptococci, gram-negative bacilli, anaerobes S. aureus, streptococci, E. corrodens, anaerobes S. aureus, streptococci, P. multocida 3
SRPS Volume 10, Issue 25, 2009 antibiotics can expose the patient to unnecessary side effects and complications and can promote the development of resistant strains. Infections with Streptococcus species present rapidly, with marked cellulitis and possibly lymphangitis. Although an antistaphylococcal penicillin or first-generation cephalosporin adequately cover S. aureus, streptococci are better covered by penicillin. Gram-negative infections might present with a cellulitis or purulent infection. Anaerobic bacteria are especially common in bite wounds, infections associated with intravenous drug abuse, and diabetics. In addition to the bacteria already mentioned, Eikenella corrodens is found in many human bite wounds 28–30 and Pasteurella multocida in many domestic animal bite wounds. 31–34 These usually are adequately covered by the addition of penicillin to an agent effective against the other gram-positive organisms. 35–37 Compared with adults, children are more susceptible to unusual pathogens and have a higher incidence of oral flora, Pseudomonas aeruginosa, and Haemophilus influenzae 38,39 associated with infections. However, the associations probably are not frequent enough to warrant a change in the initial therapy for routine infections. Nevertheless, if suggested by gram stain, if a site of distant infection is present where the pathogens are common, or if the infection does not respond promptly to the standard antibiotics, additional coverage is warranted. The presence of multiple pathogens in hand infections is probably more common than is appreciated. 40 If the patient is receiving recalcitrant to conventional antibiotic therapy, methicillin-resistant S. aureus (MRSA) must be considered. Cultures should be obtained, and an antibiotic that covers MRSA should be initiated. 27,41 Prophylactic Antibiotics Three independent studies 42–44 showed that prophylactic antibiotics do not avert infection in cases of hand lacerations. Meticulous wound débridement and care are preferred over the routine use of antibiotics in cases of hand injuries. 45 Fitzgerald et al. 46 recommend prophylactic antibiotics for hand wounds of home or industrial origin but not for farm wounds, which instead should undergo thorough débridement 4 and culture. Nylén and Carlsson 47 found no correlation between severity of infection and number of organisms present in wound or time elapsed before treatment (up to 18 hours) and further emphasized the importance of wound débridement in the care of hand injuries. Prophylactic antibiotics do have a role in cases undergoing the following procedures: 1) soft-tissue reconstructive procedures with large flaps, 2) total elbow or wrist implant arthroplasty, 3) procedures of long duration, 4) complex open hand trauma with wound contamination and extensive soft-tissue and bony injury, and 5) procedures longer than 2 hours in duration. 45 For routine surgical cases in which more than 2 hours of time elapses and prophylactic antibiotics are recommended, the choice of antibiotic typically is a first-generation cephalosporin. This typically is administered as cephalexin four times a day, but new evidence shows that administering the same total dosage in two doses is equally effective. 48 The duration of the administration of the antibiotics is unclear, but the literature does show that if the time period exceeds 4 days, the antimicrobial resistance is altered. 49 Management Although the spectrum of acute bacterial hand infections is broad, the management principles are similar for all and can be summarized as follows: rest, elevation, and immobilization in position of function adequate drainage of all loculations of pus and débridement of necrotic tissue antibiotics, determined by sensitivities from aerobic and anaerobic cultures (obtained before commencement of antimicrobial therapy) and special cultures—fungi, mycobacteria, viruses— as indicated treatment with broad-spectrum antibiotics that cover for MRSA tetanus prophylaxis for all penetrating wounds early, aggressive hand therapy Common Bacterial Infections Hand infections can be acute or chronic, but the overwhelming majority are acute. Of the acute infections, more than 90% are caused by bacterial pathogens. 20
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