Chapter 160: Incision and Drainage of Infections of the Hand

INDICATIONS

Although definitive indications for incision and drainage of infections of the hand vary with the location, duration, extent, and severity of the infection, most localized infections warrant incision and drainage or operative debridement. Particular attention must be paid to patients with immunocompromised conditions that might mask an adequate inflammatory response and delay diagnosis and treatment (e.g., an elderly diabetic presenting with a felon). Most infections arising on the volar surface of the hand produce maximal swelling on the dorsum, but dorsal drainage is used only when suppuration presents on the dorsum. If necrotizing fasciitis is suspected, either streptococcal or polymicrobial, emergent and aggressive operative debridement is warranted.

PREOPERATIVE PREPARATION

If surgery cannot be performed immediately or the diagnosis of deep infection is uncertain, immobilization, rest, and elevation of the extremity in combination with aggressive broad-spectrum antibiotic therapy are initial treatments. Once the diagnosis of abscess is made, incision and drainage are performed. Patients with comorbidities must be evaluated and treated appropriately, particularly glucose control in diabetic patients. Patients with a history of tobacco abuse should be counseled to stop all nicotine products to facilitate wound healing.

ANESTHESIA

Various anesthetic blocks can be used depending on the level and extent of anesthesia required. Axillary, brachial plexus, and Bier blocks may be used for complete anesthesia of the forearm and hand. Regional blocks of the median, ulnar, or radial nerve at the wrist can be performed with a high level of reliability. Digital blocks can be performed through either a volar or a dorsal approach, taking care to prevent excessive infiltration around the base of the digit, which can cause digital compartment syndrome and threaten circulation. Epinephrine in the hand can be used in a dilute solution, but care should be taken, especially in patients with clinical evidence of peripheral vascular disease of the affected extremity. General anesthesia is used for more extensive infections or in cases where regional anesthesia cannot be performed safely.

POSITION

Patients are placed in a supine position with the involved hand on an arm table. For procedures involving a palmar approach, the surgeon may find visualization improved by sitting on the ulnar side of the supinated hand. The opposite is true for procedure involving a dorsal approach to the pathology.

OPERATIVE PREPARATION

Routine skin preparation of the hand is performed. Except for minor procedures, a tourniquet set to 250 mm Hg is placed on the upper arm. In infectious cases, gravity exsanguination is preferred over active exsanguinations (compression with an Esmarch or an elastic bandage) to minimize any hematologic spread of infection. Then a time-out is performed.

A. FELON

DETAILS OF THE PROCEDURE

Immediate drainage is imperative to relieve increased tension and prevent ...