Soft Tissues Injuries and Infections
When is it indicated for consult a hand specialist for zone 1 fingertip injury?
*1 cm2 tissue loss* - requires a skin graft patient request/occupational concern
What is the general management for a necrotizing infection?
*Emergency surgical consult* IV emperic therapy of vancomycin + pip/tazo If GAS or Clostridium sp - penicillin + clindamycin
What is the definitive treatment for most abscesses?
*Incision and drainage*
What is the treatment for erysipelas and cellulitis?
*Mild:* oral penicillin VK/cephalosporin/dicloxacillin, clindamycin *Moderate*: IV penicillin, ceftriaxone, cefazolin, clindamycin *Severe* emergent surgical consult, empiric IV vancomycin + pip/tazo
What should be done with rings on anyone with a blunt force hand or finger injury?
*Remove!!*
What is the imaging used to detect a soft tissue foreign body?
*X-ray*: *soft tissue technique* CT/MRI: non-radiolucent object *U/S*: can also be used for retrieval
What is the treatment for purulent SSTI/cutaneous abscess - mild, moderate, severe?
*mild* (purulent infection): *incision and drainage* + warm compress *moderate* (purulent infection + systemic infection): *incision & drainage*, *culture*, TMP-SMX, or doxycycline *severe* (Failed I&D + oral Abx or SIRS): I&D, culture, *IV vancomycin, daptomycin, or linezolid*
What are the diagnostic clues for nectrotizing infections?
*pain beyond margins of infection* *pain out of proportion to appearance* *dec. pain or tissue anesthesia (late*)
Why do localized abscesses form following a puncture wound?
*retained FB*
What is the treatment and management for bartholin gland abscesses?
*word catheter placement* gyn f/u within one week
What are the management principles to care for complex hand injuries?
-minimize manipulation -X-ray -tetanus prophylaxis -IV cefazolin -*elevate and ice extremity* -*NPO status* -*pain management* -*Hand surgeon consult*
When should a fingertip wound be rechecked? How long does it take to heal?
2 days 4-8 weeks
How long should sutures be left in for a nail avulsion? How long will it take for an existing nail to be pushed out?
2 weeks 1-3 months
When should packing be replaced in a abscess drainage?
24-48 hours
What percent of injuries to the perionychium are associated with a distal fingertip fracture?
50%
What is the sutures used to treat nail bed lacteration?
6.0 absorbable suture Suture nail w/ 4.0 nylon If nail is unavailable, stent nail fold w/ metal foil
What ultrasound findings would indicate a cutaneous abscess?
A wavelike motion if fluctuance is present
What gram negative bacillus found in freshwater can cause infection in immunocompromised patients?
Aeromoonas hydrophila
What is the anesthetic and antibiotics used to treat foreign body removal?
Anesthetic: 1% Lidocaine or Marcaine 0.5% ABX: cephalexin 5-7 days
What are the most common places for a simple cutaneous abscess to arise?
Areas of friction Healthy patients diabetics
When can the end of the bone be trimmed for secondary intention healing in a zone 2, 3 fingertip injury?
Bone <0.5 cm in length & tissue loss <1 cm
What is the most common cause of bullous form of impetigo? Non-bullous?
Bullous: staphylococcus - dicloxacillin or cephalexin Non-bullous (honey-crusted): streptococcus - topical mupirocin
Which animal bite is at increased risk of infection?
Cat bites
What is the most common cause of cause of skin and soft tissue infection in ERs?
Community acquired (CA)-MRSA
What is the mechanism of injury for a subungual hematoma?
Direct blow to nail w/ bed blood vessel disruption
What is Hidradentitis Suppuritiva?
Disorder of terminal follicular epithelium in apocrine sweat gland bearing skin causing recurrent, chronic infections
What is characterized by a fingertip injury?
Distal to the level of the lunula
What is the appropriate treatment for early/late presentation of human bites?
Early: augmentin Late: IV unasyn (ampicillin/sulbactam)
What are some differentiating factors between erysipelas and cellulitis?
Erysipelas - sharply demarcated borders, can present on face Cellulitis - margins ill-defined
T/F: the majority of pilonidal abscesses heal well following incision and drainage.
False, majority will have chance of recurrence Surgical referral often indicated for definitive removal
T/F: Lacterations have a higher rate of infection than puncture wounds.
False, puncture wounds have 6-11% infection rate (1% for simple lacteration)
What are Kanavel's Signs?
Findings on the physical exam for flexor tenosynovitis. *a. pain w/ passive extension* *b. tenderness over flexor tendon sheath* *c. symmetric swelling of the finger* *d. flexed posture of finger at rest*
What is impetigo?
Highly contagious red sores/crusts or blisters on the face/arms/legs.
What is the treatment for hidradentitis suppuritiva?
I&D Culture - ABX Surgical referral for definitive treatment
What is the treatment approach for flexor tenosynovitis?
IV cefazolin Immobilize and elevate hand Consult ortho or hand specialist in ED
What antibiotics are indicated for a zone 2, 3 fingertip injury?
IV cephalosporin or 7-day course of cephalexin
When is trephination (burn hold in nail) indicated for decompression of subungual hematoma?
If >50% nail bed involved
When should a hair tourniquet be inspected for in an infant?
If infant irritated w/o obvious cause
What is the indication that a perianal abscess should be cared for by a general surgeon?
If the patient is at risk of significant infection and iatrogenic sphincter injury
What is the treatment for herpetic whitlow?
Immobilize and elevate *Acyclovir 400 mg PO quid x7-10 days or topical Acyclovir 5%*
What is flexor tenosynovitis?
Infection of flexor tendon sheath
What is paronychia?
Infection of the lateral nail-fold/perionychium with swelling & pus accumulation
What is the infection that can occur in closed fist injury/fight bites?
Infection spreading along extensor tendon
What is herpetic whitlow?
Intensely painful HSV infection of terminal phalanx -appear as grouped vesicles on an erythematous base
What is the indication to leave a foreign body in? Are bullets normally left in? What are the exceptions?
Leave: small, inert, deeply embedded & asx Bullets: normally left in place Exception: distal ischemia, thrombus formation, wall erosion, or in blood vessel lumen
What is a bartholin gland abscess?
Mucous-secreting glands at 4 or 8 o'clock position of vaginal vestibule
What is the treatment of paronychia if no fluctuance? If fluctuance or visible pus?
No fluctuance: warm soaks, elevation, immobilize, PO cephalexin Fluctuance or visible pus: *incision & drainage of lateral nail fold*, warm soak, wound recheck in 24 hours
What is the most common organism for dog bites, cat bites? What is the appropriate ABX treatment?
Pasteruella multocida Augmentin
What is cellulitis?
Progressive bacterial infection of dermis +/- subcutaenous fat assoc. w/ leukocyte infiltration & capillary dilation
What is a pilonidal abscess?
Sinus at the gluteal fold become blocked with keratin, causing a bacterial infection
What is erysipelas?
Skin infection typically involving dermis & lymphatics, more superficial than cellulitis
What are the complications of a ring tourniquet?
Swelling & restriction of venous outflow causing nerve damage, ischemia, distal gangrene
T/F: foreign body sensation is very sensitive in the first 12 hours of an injury.
True
T/F: margins of cellulitis are ill-defined.
True
T/F: symptomatic subungual hematomas can be trephinated for several days after injury.
True
What are the 3 types of Nectrotizing infections?
Type 1: most common, *gas forming*, polymicrobial Type 2: GAS, *not gas forming* - flesh eating dz Type 3: C. perfringens, *gas gangrene*
What are the antibiotics indicated for Vibrio vulnificus? Aeromonas hydrophila?
V. vulnificus: ceftazidime + doxycycline A. hydrophila: ciprofloxacin + doxycycline
What is the indication to remove a wood splinter/organic spine?
Very superficial, small splinter Subungual - otherwise can risk osteomyelitis (wedge excise the nail)
What gram negative rod can be found in saltwater and cause infection?
Vibrio vulnificus -increased risk in pts. w/ liver disease if ingested via shellfish
What are the clear indications for removal of a foreign body?
a. *high potential for inflammation/infection* b. *toxicity* c. *functional/cosmetic problems* d. *potential for later injury*
What is the most common bacteria to cover for a puncture wound? What bacteria occurs w/ plantar puncture through shoe? What is the appropriate antibiotic therapy?
a. S. aureus - cephalexin b. Pseudomonas aeruginosa - ciprofloxacin
What is the treatment approach for a felon?
a. digital block for anesthesia b. unilateral longitudinal incision & drainage - *do not cross proximally DIP or distal to tip* c. irrigate w/ cephalexin
What is the initial indication for a zone 1 finger fracture?
a. elevate and apply firm pressure b. if persistent bleeding, apply *surgical/hemostatic dressing* w/ pressure dressing gauze overlay
What are the conservative approaches for the removal of a ring tourniquet?
a. elevate hand b. lubrication or ice c. circumferential compression
How is a zone 1 finger avulsion treated?
a. irrigation w/ soapy water b. serial dressing changes, will heal by secondary intention
What are the techniques to remove a fishhook?
a. retrograde technique b. string yank method (pic) c. needle cover method d. advance and cut method
What are the most common sites of hidradentitis suppuritiva?
axilla, groin, and perianal
What is the most common cause of perianal abscess?
blockage and infection of anal glands *originate at crypto-glandular area*
What is a felon?
closed space infection of distal phalanx pulp Presents as significant pain, redness, tense & bulging pulp space
If a patient has cardiac risk factors, what additional test should be obtained for a patient presenting with cellulitis?
doppler US of LE
What complication can occur if a felon is not treated?
flexor tenosynovitis osteomyelitis
What is the complication of not treating an injury to the perionychium?
permanent nail plate deformity affecting nail growth
What are the symptoms of cellulitis?
tender, erythematous, warm/swollen skin, *margins ill-defined*, local lymphadenopathy
Which patient population is most likely to have a pilonidal abscess?
white adolescents/young adults
When can cellulitis occur post-puncture wound?
within 4 days