Deep Space Hand infections

HPI: Teenage  RHD healthy male presented initially to PCP with blister to left hand from playing baseball. Small blister incised and culture sent which eventually grew out MRSA and he was started on bactrim. On follow up 4 days later swelling worsened with worsening surrounding erythema. Denied fevers ,chills or other symptoms. Denied insect, spider or other exposures. Admitted for IV antibiotics and ortho hand consultation.

Exam: 
afebrile, vitals normal
2+ radial pulse, cap refill < 2 sec
SILT throughout hand and digits
Flexion/Extension/adduction/abduction intact and notable only for mild pain with flexion of thumb, area of fluctuance to radial aspect of palm extending from mid palm around to dosal aspect of 1st and 2nd digits; see picture

Imaging:

• Plain films-if suspect foreign body
• MRI-can provide information on extent of infection
  

Management:
Orthopedic hand consultation
Admission for IV antibiotics

•  Unasyn-DOC
  
• Ancef- alternative option
• Vancomycin- if septicemia
• Gentamicin- if penicillin allergic

Anatomy:
3 main deep spaces: potential spaces separated by fascial septum

• Thenar-bursa palmar to adductor pollicis and dorsal to flexor tendons
• Deep Palmar-dorsal and radial to hypothenar space
• Hypothenar-palmar from 5th metacarpal

Key Points:

• Deep space infections include thenar (most common), hypothenar, midpalmar (rare)
• Collar button abscess-between webspace of fingers
• Exam reveals pain, swelling, pain with finger flexion
• Differential Dx: paronychia, felon, flexor tenosynovitis
• Imaging-xray for foreign body if suspected, consider MRI 
• Consult orthopedic hand
• Admission for IV antibiotics (unasyn DOC, alternatives include ancef, vancomycin, gentamicin

By: Dr Bryon Callahan