Draining Pus in the Hand

Aims

Drain only if pus is present
- (not just for cellulitis)
Diagnosis of pus is difficult
- Can’t sleep at night because of pain
- Fluctuance
- Four cardinal signs of Kanavel
  - pain with slight passive extension of fingers
  - swelling around tendon sheath
  - tenderness to palpation
  - flexion deformity of affected finger
- if in doubt, elevate arm with IV AB’s
  - if improves, avoid surgery

Principles

GA
Tourniquet but no exsanguination
Leave all wounds open after incision
Immobilise hand in functional position
Elevate arm postop
Mobilise hand once inflammation subsides
Extensive rehabilitation

Procedure

Paronychia (nail fold)
- Short longitudinal incision at one or both corners of nail fold
Felon (pulp space)
- Direct lateral incision on lateral aspect of distal phalanx of finger
- Should be dorsal & distal to distal interphalangeal crease
- Should not extend beyond distal corner of nail
- Avoid ulnar aspect of thumb & radial aspect of index / long finger – may interfere with pinch
Web space
- Pus points to dorsal aspect but incision must be made on volar aspect
- Curved transverse volar incision following contour of web space about 5mm proximal to it
Tendon sheath infection
- 2cm transverse incision just proximal to distal palmar crease
- midlateral incision over distal end of middle phalanx
- proximally
  - blunt dissection through palmar aponeurosis
  - expose fibrous flexor sheath & A1 pulley
  - incise pulley longitudinally to expose pus
- perform distal incision so that through-and-through irrigation can be perform
Medial (Ulnar) Midpalmar space
- Transverse incision just proximal to distal palmar crease
- Length of incision determined by size of abscess
- Blunt dissection to avoid digital nerves & arteries
Lateral (radial) Midpalmar space
- 4 cm incision on ulnar side of thenar crease
- Blunt dissection to avoid damage to Common Digital Nerve
Radial bursa
- 2 incisions
  - small longitudinal incision on lateral side of proximal phalanx of thumb just dorsal to interphalangeal crease
  - along thenar crease to distal crease
- identify flexor sheath distally
- incise it to drain pus
- pass a probe directed proximally
- feel for probe proximally & cut down onto it longitudinally
Ulna bursa
- Short lateral incision on ulnar side of little finger
- Dorsal to distal interphalangeal crease
- Incise fibrous flexor sheath
- Drain pus
- Pass probe proximally
- Feel for it proximally
- Incise skin longitudinally over probe