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 (for flexor tenosynovitis)
      • ­Pain with passive extension of affected finger
      • Fusiform swelling over affected tendon
      • Tenderness to palpation of affected tendon
      • Affected finger held in slight flexion
    • If in doubt, elevate arm with IV AB’s
      • If improves, avoid surgery

Prin>Principles

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  • 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 hand therapy/rehabilitation

    • Proc>Procedure

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  • 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