Hand Abscesses

Descriptors

Hand abscess - can involve several spaces including mipalmar space, thenar, hypothenar, Parona space, dorsal subaponeurotic spaces. Horseshoe abscesses and collar button abscesses are also common.

Exam Pearls

Upper extremity neurovascular exam

Outline/mark involved area to monitor progression.

Exam findings specific to certain spaces:

• Midpalmar space abscess: swelling midpalm area, loss of concavity of palm, pain with passive stretch of digits
• Thenar space: pain and swelling over thenar area, thumb in abducted resting position, pain with thumb adduction.
• Hypothenar space: pain and swelling of hypothenar area.
• Parona space: deep space connecting ulnar and radial flexor tendon sheath, TTP palm, symptoms of FTS of small finger and thumb, median nerve irritation
• Dorsal subaponeurotic space: dorsal swelling.

Horseshoe abscess: infection spreading between the tendon sheath of the small finger and thumb, connected through Parona space. May be a sequela of pyogenic TFS.

Collar button abscess: infection in the webspace, abduction of fingers away from abscess, volar and dorsal compartment involved. No I&D in ED.

Also evaluate for pyogenic flexor tenosynovitis.

Keep necrotizing soft tissue infection in the differential.

Workup

Radiographs: AP/Lateral/Oblique affected hand

Other imaging: CT-hand/forearm to look for abscess, MRI (talk to fellow before recommending MRI)

Systemic: Monitor vital signs, be vigilant for SIRS/systemic manifestation

Labs: CBC, BMP, ESR, CRP; preop labs. Keep necrotizing soft tissue infection in the differential - Calculate LRINEC score

Other: US may be performed by the ED to help characterize abscess. Not necessary in setting of CT scans

Management

Need for acute intervention:

Superficial: bedside I&D and packing; obtain cultures
Deep: I&D in OR if patient septic

Weight-bearing and range of motion: NWB UE, elevation in skyhook

Type of immobilization: Volar resting splint

Admission or discharge status:

Deep and septic: Urgent I&D in OR
Deep non-septic: admission to medicine for IV antibiotics, possible plan for I&D in OR.
Superficial: bedside I&D, ED obs, IV antibiotics, re-evaluation in AM. Plan for discharge with daily soaks.

Anticoagulation: None

Antibiotics: - If possible obtain cultures prior to starting antibiotics - IV Vancomycin/Zosyn

Surgical Indications

Absolute: Sepsis, deep abscess, collar button abscess, horseshoe abscess

Relative: concern for proximity of vital structures around the abscess prohibiting bedside I&D, failed bedside I&D.

Not an indication: None