Last updated on March 30, 2020
Example case
30 yo RHD dominant male presents with palmar pain, swelling, and redness 1 week after getting into a fight. Upon further questioning, patient reports he may have sustained a wound in his second webspace after punching someone in the mouth during the altercation. Hand surgery consulted for “possible flexor tenosynovitis” per Emergency Room due to pain on passive extension.
On exam, patient is afebrile, active ROM fully intact, swelling/erythema/tenderness to second webspace. No tenderness or erythema along tendon sheath.
Overview
Hand infections are generally categorized by depth of involvement – superficial versus deep. Infectious processes deep to the dermis can cause an abscess in the subcutaneous space. Continuous deep space infections can spread along the deep spaces of the hand and affect fascia or synovial sheaths of tendons [1]. This can lead to necrotizing inflammation and permanent disability if timely treatment does not occur.
Collar button abscesses refer to purulent infections of the web space specifically.
Web space infections can communicate deeply with the palmar spaces of the hand. These deep spaces include hypothenar space, midpalmar space, and thenar space [2]. Here, abscesses may spread along fascial planes to damage flexor tendons.
Presentation
Patients often have history of penetrating trauma or wounds but infections can result from small fissures or unnoticed breakdowns in skin. Pain with flexion, both passive and active, are common. Localized tender erythema with or without fluctuance is present within web spaces. Erythema is seen both volarly and dorsally. Patients commonly present with an hourglass configuration at the base of the digit in an abducted position (1). Patients should not have erythema and tenderness streaking along tendon sheath course – this would favor flexor tenosynovitis. Laboratory data is oftentimes completely normal.
Procedure
Timely incision and drainage is prudent due to the imminent ability to communicate with the deep spaces. The hand should be prepped in a sterile fashion and anesthesia can be obtained via a median nerve block in this case. A local field block may also considered with epinephrine to reduce blood in the field. Longitudinal incisions are performed on dorsal and volar surfaces of the web space, taking care not to injure the neurovascular bundle. Skin in the actual web space should be avoided. The abscess is then drained and copiously irrigated; the two incisions can then be carefully communicated and a Penrose drain placed through and through, sutured into place. Antibiotics are an important adjunct and should be administered. Patients can follow up in a week for drain removal.
References
- Hand Infections and Injection Injuries. In: Bullocks J, Hsu P, Izaddoost S et al., ed. Plastic Surgery Emergencies. Principles and Techniques.. 2nd Edition. Thieme; 2017. doi:10.1055/b-005-143327
- Crosswell S, Vanat Q, Jose R. The anatomy of deep hand space infections: the deep thenar space. J Hand Surg Am. 2014;39(12):2550.