CURRENT CONCEPTS

Hand Infections
John C. Koshy, MD,* Bryce Bell, MD†

Infections are common in hand surgery and proper management is important to achieve
optimal outcomes. Although most cases are not urgent, less common, severe infections such
as flexor tenosynovitis and necrotizing fasciitis require urgent identification with both medical
and surgical management. It is common for diagnoses to be missed or delayed because
clinical and laboratory indicators are often variably present. Delayed identification and
management can result in poor outcomes with permanent deficits. This article will provide a
review of hand infections with a focus on identifying serious hand infections requiring urgent
or emergent treatment, and distinguishing these from less urgent scenarios. (J Hand Surg Am.
2018;-(-):-e-. Copyright Ó 2018 by the American Society for Surgery of the Hand. All
rights reserved.)
Key words Felon, flexor tenosynovitis, hand infection, necrotizing fasciitis, paronychia.

URGENT OR EMERGENT SCENARIOS

I
NFECTIONS ARE COMMONLY ENCOUNTERED in hand
surgery. Early identification and treatment are
essential to achieve optimal outcomes. Although
most cases are not urgent, less common, severe in-
fections require urgent identification and manage-
ment. It is common to miss or delay diagnosis in
these more serious conditions owing to variability in
clinical presentation and limited utility of diagnostic
tests. A missed or delayed diagnosis can result in
amputation or death. In these cases, time is important
and swift, accurate identification and management are
directly related to clinical outcomes.
This article will provide a framework for evalu-
ating hand infections, with a focus on identifying
serious hand infections requiring urgent or emergent
treatment and distinguishing these from less urgent
scenarios, atypical infections, and mimicking condi-
tions. Finally, general principles for management of
infections will be addressed.
From the *Division of Plastic Surgery and †Department of Orthopedic Surgery, Baylor
College of Medicine, Texas Children’s Hospital, Houston, TX.
Received for publication February 2, 2018; accepted in revised form May 8, 2018.
No benefits in any form have been received or will be received related directly or
indirectly to the subject of this article.
Corresponding author: Bryce Bell, MD, Department of Orthopedic Surgery, Baylor
College of Medicine, Texas Children’s Hospital, 18200 Katy Freeway, Suite 520, Houston,
TX 77094; e-mail: brbell@texaschildrens.org.
0363-5023/18/---0001$36.00/0
https://doi.org/10.1016/j.jhsa.2018.05.027
Four main infectious conditions require urgent or
emergent attention. These include necrotizing soft
tissue infections (NSTIs), flexor tenosynovitis, deep
hand space infections, and septic arthritis. These
conditions are urgent or emergent because substantial
morbidity is associated with delayed treatment,
including pain, stiffness, and possible amputation. In
particular, NSTIs are most worrisome because of the
potential for death.
Necrotizing soft tissue infections
Every year, there are approximately 600 to 1,200 cases
of NSTIs in the United States,1 with extremities being
the most commonly affected.2 Mortality rates vary
between 5.4% to 11.1%; amputation rates are near
25% for extremity-based infections.2,3 Certain risk
factors are independent predictors of death, including
heart disease, white blood cell count (WBC) greater
than 30,000, and creatinine greater than 2.2
This makes prompt diagnosis vitally important.
Unfortunately, the diagnosis is often unclear. Hard
signs of necrotizing fasciitis (skin necrosis, bullae,
crepitus, gas on imaging studies, and hemodynamic
instability) are not always present; one or more signs
are present less than 50% of the time.4 Laboratory
markers can aid in diagnosis, because a sodium value
less than 135 and WBC greater than 15,400 are
greater predictors of NSTI.4 In addition, the labora-
tory risk indicator for necrotizing fasciitis (LRINEC)

Ó 2018 ASSH r Published by Elsevier, Inc. All rights reserved. r 1

2 HAND INFECTIONS
score was developed to assist diagnosing these
devastating infections. The LRINEC score is based
on 6 laboratory values; a score greater than 8 in-
dicates greater than 75% chance of having an NSTI
(Table 1).5 The value of the LRINEC score is often
questioned, especially in atypical pathogens such as
Vibrio.6 One study reviewed 70 patients with Vibrio-
related NSTIs, including 18 deaths. All 18 mortalities
had an LRINEC score of less than 6.7 In cases with
an uncertain diagnosis even after clinical and labo-
ratory evaluation, a fascial biopsy can be performed
for diagnosis.
Once an NSTI is identified, the patient should be
taken emergently to the operating room for aggressive
debridement. Dishwater-like fluid along fascial planes
is a characteristic intraoperative finding. Return trips to
the operating room every 24 to 48 hours are generally
required to confirm adequate debridement of the in-
fectious nidus and prevent further tissue destruction.
A high-acuity nursing care unit is required to monitor
via signs and administer intravenous antibiotics and
vasopressors if necessary. Antibiotic regimens vary
based on the offending pathogens. Generally, young,
healthy individuals have monomicrobial infections
with group A b-hemolytic Streptococcus bacteria,
whereas patients with diabetes mellitus or other
immunosuppressive conditions have polymicrobial
infections. Broad-spectrum coverage should be
employed until culture results are available (Table 2).
Vibrio-related necrotizing fasciitis accounts for a
notable portion of all NSTIs, and the ideal regimen is
debated. However, evidence suggests that the optimal
regimen is minocycline with either a fluoroquinolone
or third-generation cephalosporin.8
Flexor tenosynovitis
Flexor tenosynovitis carries a substantial incidence of
amputation or loss of total active motion. Classically,
the diagnosis is clinical. Kanavel described 4 signs
commonly associated with these infections. However,
the clinical presentation can vary; one study found
that only 54% of patients had all 4 signs.9 Pang et al10
evaluated these clinical signs and noted that fusiform
swelling was most common (97% of patients) and
pain on passive extension of the digit was most
reliable. Pain along the flexor tendon sheath may be a
relatively late sign. Findings may be more subtle in
the thumb and little finger because of the ability of
these digits to autodecompress through the radial and
ulnar bursae when present. These bursae also provide
a portal for infection to spread proximally in the palm
to the space of Parona and then to the contralateral
side of the hand, creating a horseshoe abscess.
J Hand Surg Am.
TABLE 1. LRINEC Score
Laboratory Marker Results Score
C-reactive protein  150 mg/L 4
White blood cell 15,000e25,000/mL 1
> 25,000/mL 2
Hemoglobin 11e13.5 g/dL 1
< 11 g/dL 2
Sodium < 135 mmol/L 2
Creatinine > 1.6 mg/dL 2
Glucose > 180 mg/dL 1
The LRINEC score was developed to aid in identifying NSTIs. Scores
greater than 8 indicate a greater than 75% chance of having an NSTI.
Laboratory values have some use as an adjunct to
clinical suspicion, but they are limited by low nega-
tive predictive value.11
For individuals who present early (less than 24
hours) or with mild symptoms, some authors have
recommended management with intravenous anti-
biotic therapy alone for both diagnostic and therapeutic
purposes. In 1951, Murray12 described 2 patients with
early tenosynovitis (finger edema and pain on passive
extension) who were treated with antibiotics and had
rapid improvement in 24 hours and full, functional
recovery in 4 days. Neviaser13 also reported good
outcomes with nonsurgical management when patients
presented early. In both of these scenarios, close
monitoring was performed for the first 12 to 24 hours to
ensure clinical improvement.
When patients present late (more than 24 hours
after the onset of symptoms) or have findings
consistent with a more substantial infection, surgery
is indicated. There is some debate about the ideal
method for surgical intervention. Limited incision
methods have been increasingly reported over the
past few decades, emphasizing improved range of
motion with this method. One literature review
summarized these findings and found that 74% of
patients with a limited incision approach demon-
strated excellent outcomes, compared with 26% of
patients with aggressive surgical intervention.14 The
limited incision technique has several variations,
including the use of bupivacaine as an irrigant during
or after surgery, or both, to assist with rehabilitation
(compared with standard irrigation).15 The benefit of
postoperative irrigation has not been demonstrated in
clinical studies. A study by Lille et al16 found no
difference in clinical outcomes when intraoperative
irrigation was performed alone versus combined
intraoperative and postoperative irrigation.
r Vol. -, - 2018
 HAND INFECTIONS 3

TABLE 2. Classification and Treatment of Necrotizing Soft Tissue Infections

Type of NSTI Bacteria Responsible Antibiotics

Polymicrobial Mixed infection of aerobic Broad spectrum until pathogen(s) are identified: Piperacillin/
and anaerobic bacteria tazobactameimipenem (gram positive, negative) plus
vancomycin (gram positive, MRSA) plus clindamycin
(anaerobes)
Monomicrobial Group A Streptococcus, possible Broad spectrum until pathogen(s) identified: Piperacillin/
Staphylococcus aureus tazobactameimipenem (gram positive, negative) plus
vancomycin (gram positive, MRSA) plus clindamycin
(anaerobes)
Marine Vibrio Minocycline plus fluoroquinolone or third-generation
cephalosporin

MRSA, Methicillin-resistant S aureus.

General antibiotic treatment regimens for NSTIs based on offending pathogens and infection type.

In some cases, limited surgical intervention is

clearly insufficient and a more extensive procedure is
warranted. Michon17 attempted to classify intra-
operative findings and others sought to correlate this
with the need for a more extensile approach. Some
authors believe that when there is subcutaneous pu-
rulence, septic necrosis of the tendon or tendon
sheath, or signs of digital ischemia, an open, extensile
debridement or even amputation is required5 (Fig. 1).
Antibiotics are given after cultures are taken, but the
optimal length of therapy is unclear.

Deep hand space infections
Deep hand space infections are seen less often than
are other urgent or emergent scenarios but they can
occur in the presence of a penetrating injury or
proximal spread of flexor tenosynovitis. Each site has
unique presenting characteristics. The diagnosis is
largely made based on clinical assessment owing to
limitations in advanced imaging. Ultrasound has a
high negative predictive value but it tends to have
more false positives and ambiguous results.6
Computed tomography scans have been shown to
have sensitivity and specificity similar to those of
ultrasound imaging and are prone to hardware artifact
when present.7 Magnetic resonance imaging (MRI)
scans obtain the best soft tissue images but they take
much longer to obtain and are costlier.
Thenar abscesses tend to present with localized
swelling, erythema, and pain to the thenar eminence,
with substantial pain on thumb adduction and/or
opposition. The key to incision and drainage of these
abscesses is to address both the volar and dorsal
component, possibly with 2 incisions. The dorsal
incision addresses the retroadductor space over the
free edge of the abductor pollicis. Midpalmar
FIGURE 1: Flexor tenosynovitis: gross purulence within the
volar soft tissue as well as the flexor tendon sheath. As a result of
findings, the decision was made to perform an extensile approach
and debridement.
abscesses are characterized by loss of the palmar
concavity of the hand, often with a flexed position of
the middle and ring fingers owing to the proximity of
the flexor tendons. These are traditionally approached
through either a midpalmar transverse incision or a
hockey stick incision. Hypothenar abscesses usually
do not have digital symptoms on presentation but
they still require urgent drainage. In general, these
cases should be managed in the operating room for
optimal washout and debridement.
Septic arthritis
The warm, red, and swollen joint must be evaluated
to rule out a septic joint. Untreated septic arthritis will
erode the articular cartilage, narrow the joint space,
and may lead to ankylosis. The diagnosis may be
clear based on the clinical scenario (eg, a fight bite
now with purulent drainage), but other situations are
less obvious, such as an atraumatic, inflamed joint. In

J Hand Surg Am. r Vol. -, - 2018

4 HAND INFECTIONS
FIGURE 2: Collar button abscess: Characteristic appearance of a
collar button abscess with interdigital abscess and fingers in an
abducted position.
these cases, the differential becomes wider, including
crystalline arthropathy and rheumatoid disease. In
such cases, joint fluid analysis is helpful for diag-
nostic purposes despite difficulties in obtaining a
successful aspiration or sufficient fluid for analysis.
One study18 reviewed 104 cases of inflamed wrist
joints over a 2-year period. Eleven patients were
taken to the operating room, only 5 of whom had
confirmed septic arthritis. Interestingly, the true cases
did not have elevated laboratory markers (although
most of those individuals were immunocompro-
mised). In addition, obtaining a successful wrist
aspiration was not always possible. Only 2 of the 5
patients who were positive had a successful wrist
aspiration. One aspiration yielded no fluid and 2 had
insufficient fluid for analysis. These observations
stress the importance of making the diagnosis based
on history and physical examination. If one is able to
obtain fluid for analysis but has a minimal amount, a
review from 200719 found the greatest diagnostic
yield came from obtaining a cell count and identi-
fying the percentage of polymorphonuclear leuko-
cytes; greater than 50,000 WBC and greater than
75% polymorphonuclear leukocytes are generally
diagnostic. Once a septic joint is identified, the
J Hand Surg Am.
FIGURE 3: X-ray findings of osteopenia and cortical irregularity
in an individual with osteomyelitis who had previously under-
gone irrigation and debridement for presumed septic arthritis.
Reprinted with permission from McDonald LS, Bavaro MF,
Hofmeister EP, Kroonen LT. Hand infections. J Hand Surg Am.
2011;36(8):1403-1412.24
standard of care involves washing out the joint open
or arthroscopically. Patients managed within 3 days
of the presenting symptoms fare better than do those
managed more than 3 days after initial symptoms,
although many patients managed within 3 to 7 days
have been reported to regain range of motion in the
long term. Nonetheless, a portion of these patients
will ultimately progress to arthritis and require addi-
tional interventions.8
NONURGENT OR EMERGENT SCENARIOS
Cellulitis and abscesses
Management of the more commonly seen cellulitis and/
or abscess(es) is straightforward but still requires
diligence and attention to detail. The basic workup
involves obtaining information regarding medical
comorbidities (diabetic, renal disease, drug user, etc),
checking vital signs, marking erythema, identifying
fluid collections, and obtaining basic laboratory
values. One should also obtain radiographs to rule out a
foreign body, fracture or dislocation, and osteomyelitis.
Initial management involves updating tetanus
vaccination in penetrating injuries and giving antibi-
otics (unless just before culture collection). Drainable
fluid collections require intervention; other cases
should be monitored for a short period of 12 to 24 hours
r Vol. -, - 2018
 HAND INFECTIONS
TABLE 3. Atypical Infections by Patient History
Type Region/Category
Endemic Southwest United States
OhioeMississippi River Valley
Tropics
Activity-related Gardeners
Bird handlers
Fishing/boating activities
Sheep handlers
Systemic conditions Immunocompromised
A thorough history is critical to identify risk factors for atypical infections related to geography, activities, and comorbidities.
or with close follow-up to demonstrate improvement of
clinical findings with antibiotics. Antibiotics are
generally selected toward the clinical scenario. Given
the increasing prevalence of methicillin-resistant
Staphylococcus aureus in the community, empiric an-
tibiotics should cover this bacterium.20,21
Animal bites
Animal bites are a common cause of hand infections.
Cat bites tend to have an increased risk for wound
infection compared with dog bites. This disparity is
caused by the mechanism of injury. Dog bites tend to
leave large open wounds. However, cat bites involve
long pointed teeth, which deposit inoculum deep
within the soft tissues without an open wound to allow
for egress of fluid. Patients with dog bites should be
assessed for the risk of rabies, and cat scratches should
be evaluated and managed with consideration for
Bartonella henselae (cat scratch disease). Appropriate
first-line antibiotics for most bites is amoxicillin/
clavulanate; alternative regimens such as clindamycin
plus a fluoroquinolone (or clindamycin plus sulfa-
methoxazole and trimethoprim in a pediatric patient)
can be used if there is a penicillin allergy. Snakebites
are endemic to certain regions and are often managed
with CroFab (BTG Specialty Solutions, West Con-
shohocken, PA) or other forms of antivenin if there are
findings of local, systemic, hematologic, or neurologic
toxicity. Use of prophylactic antibiotics for snakebites
and performance of fasciotomies for possible
compartment syndrome are hotly debated.9e12
Collar button abscesses
Collar button abscesses are found in the interdigital
web spaces, volar and dorsal to the natatory ligament.
The fingers often present with a characteristic
abducted position (Fig. 2). Management involves
J Hand Surg Am.
5
Pathogen
Coccidioidomycosis
Histoplasmosis, blastomycosis
Chromomycosis
Sporothrix schenckii
Mycobacterium avium
Mycobacterium marinum, Vibrio
Orf/poxvirus
Mucormycosis, aspergillosis, candida, histoplasmosis
incision and drainage, with care taken to irrigate and
debride both the volar and dorsal components of the
abscess thoroughly with 2 separate incisions, which
often need to connect to ensure adequate drainage.
Fingertip infections
Two main infection types involve the distal fingertip:
felons and paronychia. These can be acute or chronic.
Their incidence is related to the unique anatomy of
the region, in which the tissues that surround the nail
(hyponychium, paronychium, and eponychium) form
a barrier against infectious organisms. Disruption
and/or inoculation of this barrier occurs in several
scenarios (eg, nail biting and dishwashing) and al-
lows for the entry of infectious organisms into the
fingertip tissues.
Felons present with infection involving the pulp of
the digit. The anatomy of this region is unique and
important because fibrous septae connect the perios-
teum to the skin and compartmentalize the pulp. In-
fections in this region can lead to considerable pain
from the build-up of pressure in the area. In addition,
because of the close proximity of the bone, osteo-
myelitis is always a potential concern in either the
acute or chronic setting. Early cases without a
drainable fluid collection are treated with antibiotics
and warm soaks; however, a drainable fluid collection
necessitates incision and drainage. Multiple incisions
can be used, but it is essential to incise and disrupt all
intervening septa to clear the infection.
Acute paronychia also presents with erythema,
swelling, and pain. These infections involve areas
adjacent to the nail fold, but can spread underneath
the nail plate, into the nail pulp and even wrap around
to the contralateral side. An infection adjacent to the
germinal matrix can lead to pressure necrosis and
affect subsequent nail growth. Management is
r Vol. -, - 2018
6 HAND INFECTIONS
FIGURE 4: Atypical infections can include tuberculosis, as seen
in this patient with tuberculous tenosynovitis and characteristic
caseous material. Reprinted with permission from Al-Qattan
MM, Al-Namla A, Al-Thunayan A, Al-Omawi M. Tuberculosis
of the hand. J Hand Surg Am. 2011;36(8):1413-1422.25
dictated by clinical findings. If there is no drainable
fluid collection, soaks and antibiotics with expectant
management are the standard of care. If there is a
drainable fluid collection, incision and drainage are
required, which may involve releasing the proximal
nail fold and removing part or all of the nail.
By definition, chronic paronychia is inflammation
that has been present for more than 6 weeks. Its man-
ifestations are more demonstrative of an inflammatory
process than a suppurative process. The long-standing
inflammatory reaction of the proximal nail fold leads to
fibrosis and decreased vascularity of the dorsal nail
fold. Individuals may present with nail changes
including ridging, grooving, discoloration, and/or
rounding of the nail plate. These infections are most
often seen in individuals predisposed to breakdown of
the nail plate barrier. Management generally involves
first avoiding exposure to irritants and moisture and
then use of either topical corticosteroids or topical
antifungals. One study compared cure rates with
topical corticosteroids versus topical antifungals and
found significantly improved results with corticoste-
roids.22 This supports the notion that this disease is
J Hand Surg Am.
FIGURE 5: Findings of a 7-month-old patient with the charac-
teristic appearance of herpetic whitlow, a localized herpes sim-
plex virus infection. The patient also had grouped vesicular
perioral lesions; 2 weeks later, after initiation of acyclovir and
local wound care, the vesicles were completely resolved.
primarily a chronic inflammatory condition rather than
a pure fungal infection. Regardless, fungal infections
can occur; Candida is the most common offending
pathogen. When medical therapy does not work, sur-
gical intervention may be necessary. This traditionally
involves marsupialization, removal of a portion of the
proximal eponychium, or en bloc resection of the
proximal nail fold with secondary healing.
Osteomyelitis
Osteomyelitis of the hand or digits is relatively un-
common, but like other infections it can be associated
with substantial morbidity. One study found an
amputation rate of approximately 40% in cases of
osteomyelitis, with increased risk if the initial pre-
sentation was delayed. Furthermore, presentation
greater than 6 months after the onset of symptoms or
episode of contamination had an amputation rate of
86%.23 These infections tend to occur as a result of
direct inoculation or spread from an adjacent focus.
In children, hematogenous spread occurs more
commonly and is thought to be related to anatomical
characteristics of the physis. Clinical findings include
pain, warmth, erythema, and drainage. Imaging may
be helpful, but each modality has limitations. Ra-
diographs will show signs of osteolysis, osteopenia,
r Vol. -, - 2018
 HAND INFECTIONS 7

FIGURE 6: Findings of a patient with the characteristic lesion of an orf infection. This viral infection is transmitted from sheep or goats.
Reprinted with permission from Al-Qattan MM, Helmi AA. Chronic hand infections. J Hand Surg Am. 2014;39(8):1636-1645.26

FIGURE 7: Pyoderma gangrenosum is a mimicker of hand infections, but it is important to identify this condition because its treatment
is nonsurgical. A In this case, the patient presented after excisional biopsy of a dorsal hand skin cancer with erythema, pain, and ul-
ceration surrounding the operative site. Biopsy demonstrated findings consistent with pyoderma gangrenosum. B The patient underwent
treatment with steroids and had a dramatic response after 1 week. C Complete resolution occurred at 2 months. Reprinted with
permission from Wolfe CM, Green WH, Cognetta AB Jr, Baniahmad O, Hatfield HK. Atypical pyoderma gangrenosum of the dorsal
hand mimics squamous cell carcinoma. J Hand Surg Am. 2012;37(9):1835-1838.27

osteosclerosis, or periosteal reactions, but they can
often be negative, especially early (Fig. 3). Computed
tomography scans and MRIs have limitations from a
diagnostic perspective. However, MRIs are generally
superior in their sensitivity and specificity early on,
identifying sinus tracts and defining the extent of
the infection.13,14 Some authors suggest that early
osteomyelitis can be managed with antibiotics alone.
Surgical management undoubtedly has a major role
in early osteomyelitis for 2 main reasons: obtaining
specimens for culture and debridement. Amputation
versus reconstruction depends on specific case char-
acteristics as well as patient comorbidities. More
proximal infections often warrant resection and
reconstruction from a functional perspective; how-
ever, this often is done in a staged fashion with an
intermediate procedure involving placing an anti-
biotic delivery device. In addition, systemic antibiotic
therapy is essential. The length and mode of anti-
biotic therapy are often debated, but an extended
course of 6 to 8 weeks of oral versus intravenous
antibiotics is the standard.15e18
Atypical infections and mimickers
Atypical infections can occur as a result of endemic,
activity-related, and comorbidity-related pathogens

J Hand Surg Am. r Vol. -, - 2018

8 HAND INFECTIONS
(Table 3, Figs. 4e7). This highlights the need for a
thorough social history regarding travel, occupations,
hobbies, exposure to animals, etc. Also, intraoperative
management involves sending more cultures to
include fungi and acid-fast bacilli. The clinical case
can be discussed with the microbiology laboratory
beforehand to manage the specimens appropriately.
Finally, mimickers need to be considered because their
presentation can suggest infection but their manage-
ment is different (Fig. 7). In particular, it is important to
identify pyoderma gangrenosum because its treatment
is strictly nonsurgical. Although a detailed discussion
of each disease process is beyond the scope of this
review, we encourage readers to familiarize them-
selves with common mimickers, because misdiagnosis
can notably delay healing.
CLINICAL MANAGEMENT
As mentioned, appropriate workup of potential cases
of hand infections requires a thorough history and
physical examination. It is important to identify a
history of diabetes or immunocompromise, develop
the social history, monitor the patient’s vital signs, and
use diagnostic information (serum sodium, creatinine,
and WBC values, and imaging) to supplement these
data. When designing incisions for intervention, it is
important to avoid exposing critical structures such as
nerves and tendons more than is absolutely required.
Midaxial incisions fare better than Bruner incisions
and curvilinear incisions fare better than straight
midline incisions on the dorsal hand. After debride-
ment, it is important to maintain coverage of key su-
tures to avoid an open wound requiring a more
extensive reconstructive procedure. Stiffness after in-
fections is common but it can be limited by involving
the patient early in self-directed therapy.
Hand surgeons commonly encounter the clinical
scenario of infections. Their appropriate management
is related to adherence to sound surgical principles,
close medical management, thorough evaluation to
distinguish mimickers and atypical infections, and
proper therapy and follow-up to limit disability.
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