Treatment of Infected Hand from Injury
The treatment of an infected hand from injury requires prompt surgical drainage combined with appropriate antibiotic therapy to prevent significant morbidity and mortality.
Initial Assessment and Management
Wound Cleaning and Evaluation
- Clean the affected area thoroughly with antimicrobial soap and water 1
- Assess for signs of deep infection: pain, swelling, redness, warmth, decreased range of motion, and purulent drainage 2
- Evaluate for potential complications such as:
- Pyogenic flexor tenosynovitis (Kanavel's signs)
- Deep space infections
- Involvement of joints or bones 3
Immediate Interventions
- Elevate the affected hand above heart level to reduce edema 4
- Apply warm soaks or compresses to increase blood flow to the area 5
- Immobilize the hand in a functional position using a splint 2, 3
Antibiotic Therapy
Empiric Antibiotic Selection
For superficial infections:
- First-line: Cephalexin 500 mg orally 3-4 times daily for 5-6 days 4
- Alternative: Amoxicillin-clavulanate 875/125 mg orally twice daily for 5-6 days 4
- For penicillin allergic patients: Clindamycin 300-450 mg orally three times daily for 5-6 days 4
For deep infections requiring hospitalization:
- Cefazolin 1 g IV every 8 hours 4
- For severe infections: Vancomycin plus piperacillin-tazobactam or a carbapenem 4
MRSA Coverage Considerations
Add MRSA coverage if any of these risk factors are present:
- Penetrating trauma
- Prior MRSA infection
- Injection drug use
- Systemic inflammatory response syndrome (SIRS) 4
- Local high prevalence of community-acquired MRSA 4
Surgical Management
Indications for Surgical Intervention
- Presence of abscess
- Deep space infections
- Pyogenic flexor tenosynovitis
- Clenched-fist injuries
- Failure to improve with conservative management within 24-48 hours 2, 3
Surgical Procedures
- Incision and drainage of abscesses with appropriate technique based on location:
- Copious irrigation with sterile saline 5
- Wound exploration to identify and remove foreign bodies 3
- Leave wounds open or loosely packed for drainage 2
Post-Procedure Care
Wound Care
- Apply sterile dressings and change daily 6
- For adults and children over 2 years: Apply a small amount of topical antibiotic (like bacitracin) 1-3 times daily 6
- Continue elevation and immobilization until acute inflammation subsides 4, 2
Monitoring and Follow-up
- Daily monitoring for the first 48-72 hours to ensure response to treatment 4
- Watch for signs of worsening infection:
- Increasing pain
- Fever
- Extension of erythema
- Development of bullae or skin sloughing 4
Special Considerations
Hospitalization Criteria
Hospitalize patients with:
- SIRS (fever, tachycardia, tachypnea, leukocytosis)
- Altered mental status
- Hemodynamic instability
- Concern for necrotizing infection
- Poor medication adherence
- Failure of outpatient treatment 4
Prevention of Recurrence
- Maintain good skin hygiene
- Promptly treat minor skin breaks
- Address predisposing factors (edema, obesity, eczema) 4
- For patients with 3-4 episodes per year despite treatment of predisposing factors, consider prophylactic antibiotics 4
Common Pitfalls to Avoid
- Delaying surgical drainage when indicated
- Failing to obtain appropriate cultures before starting antibiotics
- Inadequate duration of antibiotic therapy
- Overlooking deep space infections
- Not addressing underlying medical conditions that may impair healing 7, 8
- Overuse of broad-spectrum antibiotics when narrower coverage would suffice 4
Hand infections require prompt and appropriate treatment to prevent complications such as stiffness, osteomyelitis, amputation, and contracture 2, 8. With proper surgical and medical management, most patients can achieve full resolution of their infection 2.