SRPS PS - Plastic Surgery Internal

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Cellulitis Cellulitis is a common superficial infection of the hand that presents as erythema, swelling, pain, and occasional lymphangitis or vesicle formation. Cellulitis occurs most commonly on the dorsal aspect of the fingers and metacarpals, and beta-hemolytic streptococcus is the usual pathogen. Treatment includes rest, elevation, splinting, and antibiotics. Paronychia Paronychia is an infection of those structures surrounding the proximal and lateral nail. Paronychia is initiated by the introduction of bacteria between the nail and its surrounding structures. This usually is caused by minor trauma, such as nail biting and manicures. It frequently is reported that S. aureus is the most frequent isolate in paronychia. Studies have shown anaerobic bacteria to be present alone or in combination in a large percentage of cases of paronychia, 50,51 likely because of the frequency of contact of the oral secretions with the inciting wound. Paronychia initially begins as erythema, swelling, and discomfort at the nail fold, sometimes with fluctuation and frank purulence. If paronychia is detected early, warm soaks, elevation, and oral antibiotics can be sufficient treatment. If the infection has been present for longer than 24 hours or if any fluctuance is present under the nail, the nail fold must be drained by simple elevation (Fig. 3). 52,53 If the initial attempt at drainage is inadequate, if the infection extends significantly proximal to the nail fold, or if the infection fails to resolve with the above treatment, more aggressive drainage is indicated. The Figure 3. Drainage of paronychia. (Reprinted with permission from Conolly. 53 ) SRPS Volume 10, Issue 25, 2009 nail plate should be removed because it might be acting as a foreign body by that stage. It might also be necessary to incise the dorsal nail fold. Two incisions are made at right angles to the nail fold, at the 5 o’clock and 7 o’clock positions, to elevate it completely from the nail bed in the region of the infection (Fig. 4). 54 Accurate placement of the incisions minimizes the chance of subsequent eponychial retraction. Figure 4. Incisions in eponychium. (Reprinted with permission from Zook and Brown. 54 ) If the paronychia has been neglected or inadequately treated, purulence might extend around the nail to its ventral surface overlying the nail matrix. The pressure of the accumulating pus can permanently damage the germinal matrix, and removal of an appropriate section or the entire nail is indicated to adequately drain the infection. Inadequate treatment might allow the pus to spread under the nail sulcus to the opposite side, resulting in a “runaround” abscess. Occasionally, paronychia becomes a chronic problem, 55,56 perhaps from secondary mycobacterial or fungal infections, which more commonly occur in immunosuppressed patients, diabetics, and cancer patients. Chronic paronychia also occurs in patients who have frequent exposure to moist environments. Candida albicans is the most commonly identified organism in paronychia. 52 Infection can become chronic in the presence of vascular insufficiency, such as in cases of Raynaud disease or scleroderma. The chronic infections can be treated in several ways. The nail fold can be marsupialized by excision of a crescent of tissue 5
SRPS Volume 10, Issue 25, 2009 down to the germinal matrix, which is then left to close by secondary intention. 57,58 Alternatively, the entire proximal nail fold, including the cuticle, can be excised. 59 Once healed, a very satisfactory cosmetic result is achieved, although as the dorsal roof of the nail is ablated, the shiny surface layer of the nail is no longer produced. Complete removal of the nail and then treatment with a combined antifungal-steroid cream has also shown good results. 60 In cases of nonhealing chronic infection, malignancy should be ruled out considering that subungual melanoma often is unpigmented and mistaken for fungal infection. 61 Pulp Space Infection (Felons) A felon is an infection of the pulp of the distal finger. The anatomy of the pulp is unique, with 1520 longitudinal septa anchoring the tip to the distal phalanx (Fig. 5). 53 When infection is present, the septa can compartmentalize an infection and preclude adequate drainage if the septa are not fully ruptured. Figure 5. Anatomy of the fingertip. (Reprinted with permission from Conolly. 53 ) Most felons are precipitated by some sort of penetrating trauma, and radiographs should be obtained of all felons and carefully evaluated for foreign bodies. If a felon does not respond to therapy or if strong evidence indicates that a non-radiopaque foreign body is embedded in the pulp, 6 ultrasonography might reveal a foreign body not seen on conventional radiographs. S. aureus is the most common pathogen in felons, 62 but gram-negative organisms have also been reported. Gram-negative organisms should be considered in immunosuppressed patients. A number of cases have been reported in diabetics who developed felons after checking their blood sugar level by fingerstick. 63 If a pulp infection is observed early, it might simply be a case of localized cellulitis or a small superficial abscess. Localized cellulitis and small superficial abscesses can be treated with orally administered antibiotics, rest, and elevation or with local drainage as indicated. In a case of true felon, the patient presents with the entire pulp red, swollen, and markedly tender. The patient usually complains of a severe throbbing pain, particularly when the finger is dependent. The pain is caused by increased tissue pressure, which is caused by the unyielding septa (essentially a compartment syndrome of the pulp). At that stage, adequate drainage and antibiotics are required for treatment. 52,62 Late presentation or incomplete therapy can result in a compromise of the blood flow to the pulp, which can result in necrosis of the soft tissues, tenosynovitis, septic arthritis, and even osteomyelitis. 64 Many incisions have been recommended for the drainage of felons. If it is pointing, the felon should be drained at that site. Careful palpation with a small blunt probe often determines a point of maximal tenderness, and the incision should be made at that site. The pulp must be explored immediately volar to the phalanx but dorsal to the neurovascular structures. The fibrous septa are ruptured to allow complete drainage of the infected space. Good results are achieved with a longitudinal midline palmar incision that does not cross the distal interphalangeal joint (Fig. 6). 52,53 The incision heals well and usually does not produce a hypersensitive scar on the pulp. Tenosynovitis Tenosynovitis is an infection within the sheaths that form the gliding surfaces around the tenons in the hand. It is almost exclusively a disease of the flexor tendons, although extensor tenosynovitis at the level of the dorsal retinaculum has also been described. 65
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