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A 46-year-old homeless IV drug abuser presents with the hand infection shown in Figure A, which developed after sustaining a superficial laceration. Cultures are taken during operative irrigation and debridement, and he is started on antibiotic therapy. Based on the patients history, what is the most common pathogen in this setting?
Herpes simplex virus
Methicillin-resistant staphylococcus aureus
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Figure A shows an abscess over the metacarpophalangeal joint of the thumb. Infections with these characteristics in IV drug abusers are most commonly caused by MRSA, and can affect any portion of the hand.
Imahara et al retrospectively reviewed 159 hand infections treated in the operating room over an 11-year period. The examined data included known risk factors for MRSA, including human immunodeficiency virus infection, diabetes mellitus, intravenous drug use, incarceration, and homelessness. Intravenous drug use was the only independent risk factor for CA-MRSA infections.
Boucher et al examined the trends in both nosocomial and community-associated MRSA infections and explored recent studies of the mechanisms that allow S. aureus to become resistant to currently available drugs.
1-Herpes simplex virus can cause Herpetic whitlow, as shown in Illustration A, typically presents on the fingers health care workers exposed to a carriers mouth. Usually, this infection appears as small ulcers or vesicles, and operative debridement is contraindicated.
2-Candida albicans is a more rare hand infection typically associated with chronic paronychia, as shown in Illustration B.
3-Escherichia coli is a less common cause of abscess formation in the hand.
4-Eikenella is usually associated with "fight-bite" infections on the dorsal aspect of the MCP joint, and does not commonly occur after superficial lacerations. It can also rarely occur in IV drug users who clean their needles with saliva, as Eikenella is part of the normal oral flora. An example of an Eikenella infection is shown in Illustration C.
Imahara SD, Friedrich JB
J Hand Surg Am. 2010 Jan;35(1):97-103. PMID: 19962836 (Link to Abstract)
Imahara, JHS 2010
Boucher HW, Corey GR.
Clin Infect Dis. 2008 Jun 1;46 Suppl 5:S344-9. PMID: 18462089 (Link to Abstract)
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All of the following are considered the cardinal signs of flexor tenosynovitis EXCEPT:
Tenderness along the flexor tendon sheath
Flexed resting posture of the finger
Fusiform swelling of the finger
Pain on passive extension of the finger
Pain on passive flexion of the finger
The cardinal signs of pyogenic flexor tenosynovitis (Kanavel signs) include:
1) partially flexed resting posture of the involved finger
2) pain with passive extension
3) fusiform swelling of the finger
4) volar tenderness along the flexor sheath
Patients commonly present 24 to 48 hours after onset of symptoms. The standard of care is “urgent surgical drainage” to avoid tendon scarring or necrosis with subsequent impairment of finger function followed by intravenous antibiotic administration.
According to Hand Surgery Update 3, open sheath irrigation has been replaced largely by closed sheath irrigation. These authors cite a retrospective study that showed no statistical difference in resolution of infection using open sheath irrigation or closed sheath irrigation, however, there was a trend towards more frequent complications and reoperations in the open drainage group.
Lille et al reviewed the records of 75 patients with pyogenic flexor tenosynovitis and found that there was no difference in outcomes between those who received intraoperative irrigation only versus those receiving intraoperative irrigation and continuous postoperative irrigation.
Lille S, Hayakawa T, Neumeister MW, Brown RE, Zook EG, Murray K
J Hand Surg Br. 2000 Jun;25(3):304-7. PMID: 10961561 (Link to Abstract)
Lille, JHANDS 2000
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Percutaneous irrigation technique
Flexor tenosynovitis is diagnosed by the presence of Kanavel's Four Cardinal Sig...