What is the recommended management for hand phlegmon?

Management of Hand Phlegmon

Hand phlegmon requires urgent surgical exploration and drainage combined with empirical antibiotic therapy targeting Staphylococcus aureus and beta-hemolytic streptococci, as delayed surgical intervention is associated with poor functional outcomes including digital stiffness and amputation. 1, 2, 3

Immediate Assessment Priorities

Critical Examination Elements

• Evaluate for underlying tendon, nerve, and neurovascular injuries immediately, as surface examination is inadequate and wound appearance does not correlate with extent of damage 4
• Check digital perfusion and capillary refill—absent pulses or decreased perfusion mandate emergent intervention to prevent limb loss and ischemic contracture 4
• Assess for Kanavel's four cardinal signs if flexor tenosynovitis is suspected: fusiform finger swelling, flexed posture at rest, pain with passive extension, and tenderness along the flexor sheath 3
• Document total active motion and neurovascular status before intervention 3

Pre-Procedure Hand Hygiene

• Perform surgical hand antisepsis using antimicrobial soap or alcohol-based hand rub with persistent activity before donning sterile gloves 5, 6
• Scrub hands and forearms for 2-6 minutes when using antimicrobial soap (long 10-minute scrubs are unnecessary) 5

Surgical Management

Indications for Urgent Surgical Exploration

• Any suspected hand phlegmon requires emergency surgical exploration, not primary antibiotic prescription alone 3
• Surgical debridement of devitalized tissues and drainage of fluid collections is integral to appropriate management 7
• The majority of hand infections (72%) require operative treatment 8
• Delayed surgical management is a poor prognostic factor associated with digital stiffness and amputation 3

Intraoperative Considerations

• Obtain aerobic and anaerobic cultures during surgical exploration 8
• Expect multiple organisms (84% of hand infections contain multiple isolates, averaging over three organisms per infection) 8
• Human bite wounds contain anaerobes 43% of the time compared with 12% for other wounds 8

Antibiotic Therapy

Empirical Antibiotic Selection

• First-line empirical therapy is a first-generation cephalosporin (cefazolin IV followed by cephalexin PO) or an antistaphylococcal penicillin (methicillin IV followed by dicloxacillin PO), as 80-90% of community-acquired pathogens remain susceptible 7, 8
• For community-acquired hand phlegmon, target Staphylococcus aureus and beta-hemolytic streptococci, which cause the majority of infections 1, 2, 7
• Amoxicillin-clavulanate 875/125 mg twice daily is appropriate for oral therapy in high-risk wounds 6
• For penicillin-allergic patients, use clindamycin rather than macrolides due to global emergence of macrolide-resistant S. aureus and streptococci 7

Special Pathogen Considerations

• Beta-hemolytic Streptococcus group A is associated with rapid progression and poor prognosis 3
• Presence of anaerobes, Eikenella corrodens (human bites), or increasing number of organisms is associated with unsatisfactory treatment response 8
• Consider broader coverage for nosocomial infections: piperacillin/tazobactam with or without vancomycin depending on local resistance patterns 7

Duration of Therapy

• Prophylaxis duration for high-risk wounds: 3-5 days 6
• Established soft tissue infection: continue until clinical resolution
• Septic arthritis if present: 3-4 weeks 6
• Osteomyelitis if present: 4-6 weeks 6

Risk Stratification and Prognostic Factors

Poor Prognostic Indicators

• Advanced stage of infection at presentation (Michon-Sokolow Stage II or III) 3
• Beta-hemolytic Streptococcus group A infection 3
• Delayed surgical management 3
• Smoking (newly identified risk factor) 3
• Diabetes or immunodeficiency 3

Expected Functional Outcomes by Stage

• Stage I: Total Active Motion 240°, QuickDASH score 20/100, return to work 1 month 3
• Stage II: Total Active Motion 140°, QuickDASH score 56/100, return to work 4 months 3
• Stage III: Total Active Motion 40°, QuickDASH score 90/100, return to work 12 months 3

Adjunctive Measures

Wound Management

• Irrigate thoroughly with sterile normal saline and remove superficial debris 6
• Avoid iodine or antibiotic-containing irrigation solutions 6
• Adequate debridement of devitalized tissues is essential in addition to systemic antibiotics 7

Tetanus Prophylaxis

• Administer tetanus toxoid if not vaccinated within 10 years (Tdap preferred if not previously given) 4
• For dirty wounds, give booster if >5 years since last dose 4

Critical Pitfalls to Avoid

• Never treat suspected hand phlegmon with antibiotics alone without surgical exploration—this leads to progression and poor functional outcomes 3
• Do not rely on surface examination to rule out deep structure involvement 4
• Do not delay surgical intervention for imaging or culture results in clinically evident infection 3
• Avoid empiric macrolide therapy in penicillin-allergic patients due to high resistance rates 7