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1914 SECTION 23: Musculoskeletal Disorders B-cell reduction (although to a lesser extent than T cells), and in chronic use, a decrease in immunoglobulin G and immunoglobulin A. CRITICAL ACTIONS FOR SYSTEMIC RHEUMATIC DISEASE PATIENTS Important actions and facts about the care of patients with systemic rheumatic disease are listed in Table 282-8. REFERENCES The complete reference list is available online at www.TintinalliEM.com. TABLE 282-8 Critical Actions for the Care of Rheumatologic Disease Patients in the ED Rheumatoid arthritis •   Increased risk of ACS in absence of traditional risk factors; treat as ACS equivalent •   Atlantoaxial subluxation; avoid neck extension with intubation Lupus •   Increased risk of ACS in absence of traditional risk factors; treat as ACS equivalent; consider ACS in young lupus patient with chest pain Scleroderma •   Avoid steroids because they may precipitate renal crisis •   Scleroderma renal crisis (renal failure, hypertension, MAHA) is an emergency; prompt treatment with ACE inhibitors is mandatory Ankylosing spondylitis •   Spinal fractures may occur with minimal to no trauma; plain radiographs frequently miss fractures; consider CT/MRI if clinical suspicion high Raynaud’s phenomenon •   If refractory or ischemia present, topical nitroglycerin paste can be applied to webbed spaces of fingers to help save tissue Septic arthritis •   Concurrent crystalline disease does not rule out a concurrent septic arthritis; await cultures •   A negative Gram stain is insufficient to rule out septic arthritis Giant cell arteritis •   Consider in new-onset headache, jaw claudication, scalp tenderness, or visions changes •   If clinical concern high, start high-dose steroids (prednisone 1 milligram/kg) prior to obtaining biopsy for confirmation Abbreviations: ACE = angiotensin-converting enzyme; ACS = acute coronary syndrome; MAHA = microangiopathic hemolysis. Nontraumatic Disorders of the Hand Carl A. Germann  HAND INFECTIONS PATHOPHYSIOLOGY The most common pathogens causing hand infection are Staphylococcus aureus, Streptococcus species, and gram-negative species. 1 Most routine infections involve a single gram-positive organism, whereas infections from IV drug use or mouth flora are usually polymicrobial. In most U.S. cities, community-associated methicillin-resistant S. aureus is the most common pathogen cultured from patients with skin and soft tissue infections in EDs, 2 including 47% to 78% of hand infections.3-8 Injection drug users typically present with abscesses or deep space infections secondary to S. aureus and gram-negative organisms. 9 These infections are most commonly caused by direct introduction, but hematogenous spread from bacterial endocarditis is a possibility (see Chapter 296, “Injection Drug Users”). Paronychia and felons are caused by minor trauma, chewing fin gernails, or exposing minor injuries to saliva. Most of these infections are polymicrobial, including S. aureus (most common) and anaerobic bacteria. 8,9 Infections caused by animal bites reflect the oral flora of the involved species. Bites introduce a broad range of bacteria, including grampositive, anaerobic, and gram-negative organisms. Common pathogens include streptococci, staphylococci, Haemophilus, Eikenella, Fusobacterium, peptostreptococci, Prevotella, and Porphyromonas species. 10 Cat and dog bites harbor Pasteurella multocida , which typically produces an aggressive, rapidly spreading cellulitis that becomes suppurative.

am-negative organisms. Common pathogens include streptococci, staphylococci, Haemophilus, Eikenella, Fusobacterium, peptostreptococci, Prevotella, and Porphyromonas species. 10 Cat and dog bites harbor Pasteurella multocida , which typically produces an aggressive, rapidly spreading cellulitis that becomes suppurative. Hand infections are also discussed in Chapter 46, “Puncture Wounds and Bites. ” Patients with diabetes or acquired immunodeficiency syndrome have common bacterial infection or develop atypical infections, including those caused by Mycobacterium or Candida albicans. Those who are immunocompromised or asplenic are at risk for rapid progression and require prompt source control and antibiotics. PRINCIPLES OF EVALUATION AND MANAGEMENT Hand infections are most commonly introduced by an injury to the dermis. The infection initially may remain superficial and broader, termed cellulitis, or may be localized, as seen in a paronychia or felon. Left untreated, infections may spread along anatomic planes or to adjacent compartments in the hand. Deeper injuries may directly seed underlying structures, creating rapidly spreading infections such as those seen with closed fist injuries or cat bites. Obtain a directed history to delineate a likely cause of the infection. The physical examination should note the anatomic limits of the infec tion. Look for skin, subcutaneous tissue, tendon, joint, or bone involvement. If deep structures of the hand are involved, emergently consult a hand specialist because treatment likely will involve inpatient care and operative drainage. With the exception of superficial cellulitis, hand infections are man aged using basic principles. First, incise and drain any abscess. Super ficial and discrete infections, such as paronychia and felons, can be drained in the ED. Deep infections are better treated in the operating room by a hand surgeon. Second, immobilize and elevate the extremity. This will rest the hand, reduce inflammation, avoid secondary injury, and limit extension of the infection. Immobilize by applying a bulky hand dressing and splinting the hand in a position of function: the wrist at 15 to 30 degrees of extension, the metacarpophalangeal joints at 50 to 90 degrees of flexion, and the interphalangeal joints at 5 to 15 degrees of flexion (Figure 283-1). Elevate the hand on pillows or suspended using stockinette. Third, use broad-spectrum antibiotics initially targeting possible common and serious bacteria, altering only based on response and culture results ( Table 283-1). Empiric treatment for these infec tions should be based on local antibiotic resistance patterns. Fourth, if the patient is not admitted to the hospital, ensure reexamination within 48 hours. CELLULITIS Cellulitis is the most superficial of hand infections and is treated with oral antibiotics absent widespread involvement or systemic signs. Microbes most commonly breach the cutaneous surface through cracked skin, local trauma, or surgery. Diagnosis is made by documenting erythema, warmth, and edema in the affected portion of the hand without any involvement of deeper structures in the hand. Specifically, range of motion of the digits, hand, or wrist should not be painful, and palpation of the deeper structures of the hand should not produce any tenderness. The most common offending organisms are S. aureus (predominantly methicillin-resistant) 1-8 and Streptococcus pyogenes. Initial treatment is CHAPTER Tintinalli_Sec23_p1881-1932.indd 1914 8/2/19 3:15 PM

or wrist should not be painful, and palpation of the deeper structures of the hand should not produce any tenderness. The most common offending organisms are S. aureus (predominantly methicillin-resistant) 1-8 and Streptococcus pyogenes. Initial treatment is CHAPTER Tintinalli_Sec23_p1881-1932.indd 1914 8/2/19 3:15 PM CHAPTER 283: Nontraumatic Disorders of the Hand 1915 listed in Table 283-1. Cases of cellulitis without systemic signs of infec tion and a low suspicion for methicillin-resistant S. aureus should receive an antimicrobial agent that is active against streptococci. 11 For patients with cellulitis associated with purulent drainage, penetrating trauma, evidence of methicillin-resistant S. aureus infection elsewhere, nasal colonization with methicillin-resistant S. aureus, injection drug use, or sys temic inflammatory response syndrome, antimicrobial treatment effective against methicillin-resistant S. aureus and streptococci is recommended.11 Empiric monotherapy with trimethoprim-sulfamethoxazole or doxycycline is not recommended given the limited published efficacy data and concerns about effectiveness against streptococci. 10,11 Given the increasing rates of methicillin-resistant S. aureus and difficulty distinguishing among the types of S. aureus cellulitis, routine empiric treatment of methicillin-resistant S. aureus may be considered. In addition, the choice of antibiotic should be based on cultures (if available) and local resis tance patterns. Consider empiric broad-spectrum antibiotics such as vancomycin and piperacillin-tazobactam ( Table 283-1) and admission for the immunocompromised, those with clinical toxicity, and those with rapidly spreading infections. Hospitalization is recommended if there is concern for a deeper or necrotizing infection, for patients with poor adherence to therapy, for infection in a severely immunocompro mised patient, or if outpatient treatment is failing. For all cases of cellulitis, immobilize the hand in a position of func tion, and make sure the patient keeps the hand elevated as much as possible. Remove digit rings and give tetanus prophylaxis as needed. For those discharged, arrange reexamination within 48 hours. FLEXOR TENOSYNOVITIS Infectious flexor tenosynovitis is a surgical emergency. Failure to accu rately diagnose and manage flexor tenosynovitis may result in adhe sions, tendon vascular compromise and necrosis, or extension into FIGURE 283-1. Positioning the hand during immobilization. Top position is used when splints are applied in fractures or severe sprains. Bottom position is the position of function used when applying a soft bulky dressing. TABLE 283-1 Initial Antibiotic Coverage for Common Hand Infections Infection Initial Antimicrobial Agent(s) Likely Organisms Comments Cellulitis MSSA coverage: Cephalexin, 500 milligrams PO four times per day for 7–10 d, * or dicloxacillin, 500 milligrams PO four times daily for 7–10 d, or clindamycin 300–450 milligrams PO four times daily for 7–10 d MRSA coverage†: Clindamycin, 300–450 milligrams PO four times daily for 7–10 d, or doxycycline, 100 milligrams PO twice a day for 7–10 d, or minocycline, 100 milligrams PO twice a day for 7–10 d, or TMP-SMX double strength, 1–2 tablets twice per day PO for 7–10 d For severe cellulitis ‡: Vancomycin, 1 gram IV every 12 h, or linezolid, 600 milligrams IV every 12 h Staphylococcus aureus (MRSA) Streptococcus pyogenes Clindamycin is an option, but increasing MRSA resistance to clindamycin has been reported. Consider local resistance patterns. Consider vancomycin for injection drug abusers.

re cellulitis ‡: Vancomycin, 1 gram IV every 12 h, or linezolid, 600 milligrams IV every 12 h Staphylococcus aureus (MRSA) Streptococcus pyogenes Clindamycin is an option, but increasing MRSA resistance to clindamycin has been reported. Consider local resistance patterns. Consider vancomycin for injection drug abusers. Felon/paronychia TMP-SMX double strength, 1–2 tablets twice per day PO for 7–10 d * Plus/minus cephalexin, 500 milligrams PO four times per day for 7–10 d, * or dicloxacillin, 500 milligrams PO four times daily for 7–10 d * Consider addition of clindamycin or amoxicillin-clavulanate to TMP-SMX (rather than cephalexin) if anaerobic bacteria are suspected S. aureus (MRSA), S. pyogenes, anaerobes, polymicrobial Antibiotics indicated for infections with associated localized cellulitis; otherwise, drainage alone may be sufficient. Culture recommended by hand surgeons. 4-7 Flexor tenosynovitis Ampicillin-sulbactam, 1.5–3 grams IV every 6 h, or cefoxitin, 2 grams IV every 8 h, or piperacillin-tazobactam, 3.375 grams IV every 6 h Plus: Vancomycin, 1 gram IV every 12 h, if MRSA is prevalent in community S. aureus, streptococci, anaerobes, gram negatives Parenteral antibiotics are indicated; consider ceftriaxone for suspected Neisseria gonorrhoeae. Deep space infection Ampicillin-sulbactam, 1.5–3 grams IV every 6 h, or cefoxitin, 2 grams IV every 8 h, or piperacillin-tazobactam, 3.375 grams IV every 6 h Plus: Vancomycin, 1 gram IV every 12 h, if MRSA is prevalent in community S. aureus, streptococci, anaerobes, gram negatives Inpatient management. Animal bites (including human) If no visible signs of infection: amoxicillin/clavulanate, 875/125 milligrams PO twice daily for 5 d For active signs of infection: ampicillin-sulbactam, 1.5–3 grams IV every 6 h, or cefoxitin, 2 grams IV every 8 h, or piperacillin-tazobactam, 3.375 grams every 6 h For penicillin allergy, use clindamycin plus moxifloxacin or TMP-SMX and metronidazole S. aureus, streptococci, Eikenella corrodens (human), Pasteurella multocida (cat), anaerobes, and gramnegative bacteria All animal bite wounds should receive prophylactic oral antibiotics. Herpetic whitlow Acyclovir, 400 milligrams PO three times daily for 10 d Herpes simplex No surgical drainage is indicated. Abbreviations: MRSA = methicillin-resistant Staphylococcus aureus; MSSA = methicillin-sensitive Staphylococcus aureus; TMP-SMX = trimethoprim-sulfamethoxazole. *Although many sources recommend 7 to 10 days of therapy, the Infectious Diseases Society of America recommends 5 days of therapy if symptoms resolve and to continue therapy if symptoms persist. †For patients whose cellulitis is associated with purulent drainage, penetrating trauma, evidence of MRSA infection elsewhere, nasal colonization with MRSA, injection drug use, or systemic inflammatory response syndrome, vancomycin or another antimicrobial active against both MRSA and streptococci is recommended. ‡Severe infection: failed oral antibiotic treatment, systemic signs (sepsis), immunocompromised, or clinical signs of deeper infection. Tintinalli_Sec23_p1881-1932.indd 1915 8/2/19 3:15 PM

temic inflammatory response syndrome, vancomycin or another antimicrobial active against both MRSA and streptococci is recommended. ‡Severe infection: failed oral antibiotic treatment, systemic signs (sepsis), immunocompromised, or clinical signs of deeper infection. Tintinalli_Sec23_p1881-1932.indd 1915 8/2/19 3:15 PM 1916 SECTION 23: Musculoskeletal Disorders adjoining deep spaces. This can lead to loss of function of the digit and eventually loss of function of the entire hand. The diagnosis is supported by the presence of the classic clinical signs described by Kanavel 1; however, the absence of Kanavel’s signs does not exclude the diagnosis of flexor tenosynovitis (Table 283-2). The infection usually is associated with penetrating trauma of the affected area 2 to 5 days prior to presentation, although the patient may be unaware of injury. Staphylococcus is the most common bacterium isolated; however, infections often harbor anaerobes or are polymicrobial. Suspect disseminated Neisseria gonorrhoeae in a patient with a recent history consistent with a sexually transmitted infection (see Chapter 153, “Sexually Transmitted Infections”). Initiate treatment with parenteral antibiotics because the infection can spread rapidly through deep fascial spaces ( Table 283-1). The use of vancomycin is recommended because of the high prevalence of methicillin-resistant S. aureus in most communities. Send any sponta neous exudate for Gram stain and culture with sensitivities. An agent active against enteric gram-negative bacilli should be added for infec tion in immunocompromised patients or following open trauma to the muscles. Immobilize and elevate the hand, and consult the hand surgeon in the ED. If the infection is identified early in its course, nonoperative therapy with parenteral antibiotics, immobilization, elevation, and reevaluation is a common path. DEEP SPACE INFECTIONS Deep space infections arise from penetrating inoculation, contiguous spread, and rarely, hematogenous seeding. 1 S. aureus and Streptococcus species are the most common organisms isolated.1 Compartments where infection may propagate and migrate include the thenar space, midpalmar space, radial bursa (sheath for the flexor pollicis longus), and ulna bursa (common flexor sheath); see Figure 268-9 in Chapter 268, “Injuries to the Hand and Digits. ” The volar aspect of the hand is covered by the tough and fixed tissues. The veins and lymphatics course through the softer tissues on the dorsum of the hand. Therefore, the dorsum of the hand often swells whenever there is an inflammatory or infectious process. For this reason, a deep space infection initially may be misdiagnosed as a cellulitis over the dorsum of the hand. An ideal examination includes palpation of the volar surface of the hand to elicit tender ness, induration, or fluctuance. Range of motion of the digits often produces marked pain for patients with deep space infection. Pointof-care US can assist in differentiating simple cellulitis from deep space infections. 12,13 Occasionally, infections will arise in the web space. These “collar button” abscesses present with pain and swelling of the web space causing separation of the affected digits. Examination reveals induration or fluctuance in the dorsal and/or volar web space, along with erythema, warmth, and tenderness. Give parenteral antibiotics (Table 283-1) and analgesia, and immobilize and elevate the hand. Operative draining is often needed, requiring emergent hand surgeon consultation. INFECTIONS FROM CLOSED FIST INJURIES Human bite injuries to the hand may occur due to accidental trauma or purposeful biting, but are often the result of striking another individual’s teeth with a clenched fist ( Figure 283-2).

the hand. Operative draining is often needed, requiring emergent hand surgeon consultation. INFECTIONS FROM CLOSED FIST INJURIES Human bite injuries to the hand may occur due to accidental trauma or purposeful biting, but are often the result of striking another individual’s teeth with a clenched fist ( Figure 283-2). These injuries, termed “fight bite infections, ” usually occur over the dorsal aspects of the third, fourth, and fifth metacarpophalangeal joints. Although these injuries may at first appear innocuous, morbidity can result from late presentation or inadequate initial management. Because of the force and the penetrating nature of the human incisor, closed fist infections tend to occur in multiple planes and spread rapidly to adjacent compartments. Skin, extensor tendons, joint space, bone, and surrounding deep spaces often are involved because the inoculum may traverse all these structures. On examination, document the extent of the infection. Plain radio graphs will detect fractures or foreign material including tooth frag ments. The most common organisms reflect the natural flora of the mouth and include Streptococcus species, S. aureus, Eikenella corrodens, Fusobacterium, Peptostreptococcus, and Candida species; polymicrobial sources are common. Early antimicrobial therapy against both aerobic and anaerobic bacteria is recommended for patients with animal bites to the hand (Table 283-1). If you suspect any deep space, palmar space, joint, or tendon infection, give broad-spectrum antibiotics and consult a hand surgeon for open debridement and irrigation in the operating room. Closing animal bite wounds of the hand may be associated with a high infection rate. Treat all infections with hand elevation and splinting in the position of function. PARONYCHIA Paronychia is an infection of the lateral nail fold or perionychium, occasionally extending to the cuticle or eponychium. It is usually caused by minor trauma such as nail-biting, manicures, or embed ded lateral nails (“hangnails”). The infection often starts as a small area of induration that progresses to eponychial swelling, tenderness, erythema, and drainage. Most cases of paronychia contain both aero bic and anaerobic bacteria, with S. aureus and Streptococcus species the most common aerobic bacteria cultured. Chronic paronychia (>6 weeks) can occur, particularly in patients who are immunocompro mised, and may include usual pathogens or atypical bacteria and fungi such as with C. albicans. Absent fluctuance, treat the paronychia with warm soaks, elevation, and antibiotics (Table 283-1). Suppuration leads to either fluctuance or identifiable pus requiring drainage. Recommendations for drain age include the use of a digital nerve block and avoidance of incision across the eponychial fold to prevent nail deformity (Figure 283-3 ). Minor infections can be treated with elevation of the perionychium or eponychium with a flat probe to encourage drainage. If drainage is FIGURE 283-2. Clenched fist injury. The lacerations in this photograph were sustained from teeth during a fight. Note the subtle black ink stamp across the proximal metacarpals, possibly revealing a clue about the wound’s etiology. [Photo contributor: Lawrence B. Stack, MD. Reproduced with permission from Knoop KJ, Stack LB, Storrow AB, Thurman RJ (eds): The Atlas of Emergency Medicine , 3rd ed.

stained from teeth during a fight. Note the subtle black ink stamp across the proximal metacarpals, possibly revealing a clue about the wound’s etiology. [Photo contributor: Lawrence B. Stack, MD. Reproduced with permission from Knoop KJ, Stack LB, Storrow AB, Thurman RJ (eds): The Atlas of Emergency Medicine , 3rd ed. New York, NY: McGraw-Hill, Inc.; 2010, Fig 11-30.] TABLE 283-2 Kanavel’s Four Cardinal Signs of Flexor Tenosynovitis Percussion tenderness Tenderness over the entire length of the flexor tendon sheath Uniform swelling Symmetric finger swelling along the length of the tendon sheath Intense pain Intense pain with passive extension Flexion posture Flexed posture of the involved digit at rest to minimize pain Tintinalli_Sec23_p1881-1932.indd 1916 8/2/19 3:15 PM

nderness over the entire length of the flexor tendon sheath Uniform swelling Symmetric finger swelling along the length of the tendon sheath Intense pain Intense pain with passive extension Flexion posture Flexed posture of the involved digit at rest to minimize pain Tintinalli_Sec23_p1881-1932.indd 1916 8/2/19 3:15 PM CHAPTER 283: Nontraumatic Disorders of the Hand 1917 successful, use warm soaks for days after care. In general, only nonviable tissue can be incised without provoking pain. More extensive infections that do not communicate directly with the nail fold require digital block and incision directly into the area of greatest fluctuance. Severe infections with pus beneath the nail require removal of a portion of the lateral or proximal nail to ensure adequate drainage. Rarely, a free-floating nail will be encountered on a bed of pus, necessitating removal of the entire nail. Following incision and drainage, keep the hand elevated and immo bilized. Warm soaks may be initiated to keep the wound open and clean. Routine antibiotics are not needed unless cellulitis, immuno compromise, or vascular insufficiency exists; when used, a 7-day course is common or until resolution of the infection. 15 In complicated or drained cases, reassess the wound within 48 hours. Chronic paronychia (>6 weeks) should be treated with topical corticosteroids and topical antifungal agents, by avoiding wet environments, and with referral to dermatology. 1 (See Video: Paronychia Incision and Drainage.) FELON A felon is a subcutaneous pyogenic infection of the pulp space of the distal finger or thumb. 1 The septa of the finger pad produce multiple individual compartments and confine the infection under pressure. This results in a red, tense, and markedly painful distal pulp space. Infec tion typically begins with minor trauma, often a puncture wound, to the dermis overlying the finger pad. The infection can start and spread between septae, forming multiple compartmentalized abscesses. Left untreated, the infection may spread to the flexor tendon sheath, caus ing flexor tenosynovitis, or to the underlying periosteum, resulting in osteomyelitis. S. aureus is the most common organism (primarily methicillinresistant S. aureus), 3 but Streptococcus species, anaerobes, and gramnegative organisms are frequent. If possible, obtain a Gram stain and culture because these infections may be difficult to eradicate and chronic infections may be caused by atypical organisms. If osteomyeli tis occurs, identification of the offending organism guides long-term antibiotic therapy. Drain the infection if the finger pad is swollen and tense or if there is any palpable fluctuance. 1 A digital block using a long-acting anesthetic is ideal for comfort (see Chapter 36, “Local and Regional Anesthesia”). A unilateral longitudinal approach spares the sensate volar pad and achieves adequate drainage ( Figure 283-4A). Do not incise the distal end of the finger pad because this can cause instability and loss of sen sation to the fingertip. Dissect the septa using a small clamp to ensure complete drainage. A small wick encourages continued drainage. If the felon is pointing toward the volar fat pad, an option is a lon gitudinal volar approach, depicted in Figure 283-4B. Avoid extending the incision to the flexor crease of the distal interphalangeal joint. More extensive incisions such as the “fishmouth, ” “hockey stick, ” and through-and-through incisions are not indicated because these can alter sensation to the fingertip or compromise pulp vascularity. Following drainage, irrigate the wound and place a dry, sterile dress ing; ask the patient to keep the extremity elevated. Reevaluate the wound within 48 hours, and use warm soaks to keep the wound clean and pro mote continued drainage.

because these can alter sensation to the fingertip or compromise pulp vascularity. Following drainage, irrigate the wound and place a dry, sterile dress ing; ask the patient to keep the extremity elevated. Reevaluate the wound within 48 hours, and use warm soaks to keep the wound clean and pro mote continued drainage. Most felons have associated cellulitis that should be treated with oral antibiotics (Table 283-1). Refer chronic felons or felons not responding to the previously discussed treatments to a hand specialist for more definitive management and long-term follow-up. (See Video: Felon Incision and Drainage.) FIGURE 283-3. Paronychia. A. The eponychial fold is elevated using a flat probe or a #11 blade to allow the wound to drain. B. Alternatively, for more extensive infections, a #11 blade may be used to incise the area of greatest fluctuance directly into the eponychium. The wound may then be gently probed with a small clamp to ensure drainage. FIGURE 283-4. Felon. A. The unilateral longitudinal approach is the most frequently used method for draining felons. This approach minimizes interference with sensate areas of the finger pad. B. If the felon is pointing toward the volar surface of the finger pad, the longitudinal volar approach may be used. Tintinalli_Sec23_p1881-1932.indd 1917 8/2/19 3:16 PM

ngitudinal approach is the most frequently used method for draining felons. This approach minimizes interference with sensate areas of the finger pad. B. If the felon is pointing toward the volar surface of the finger pad, the longitudinal volar approach may be used. Tintinalli_Sec23_p1881-1932.indd 1917 8/2/19 3:16 PM 1918 SECTION 23: Musculoskeletal Disorders HERPETIC WHITLOW Herpetic whitlow is a viral infection of the distal finger caused by the herpes simplex virus, usually from contact with oral herpetic infections. Herpetic whitlow in children tends to be associated with gingivostoma titis and herpes simplex virus type 1, whereas adults most commonly harbor herpes simplex virus type 2. Healthcare workers, often nurses and respiratory and dental technicians, are at increased risk of this infection given their exposure to orotracheal secretions. The patient develops a burning, pruritic sensation similar to all her pes simplex infections. On examination, the lesion is erythematous and tender, with vesicular bullae (Figure 283-5). The infection occurs 2 to 14 days after contact, usually maturing in 14 days. 16 The finger may be indurated, but is not tense, as is seen in a felon. Do not mistake herpetic whitlow for a felon because incision and drainage may result in a secondary bacterial infection and prolonged failure to heal. If there is any question concerning the diagnosis of herpetic whitlow, a vesicle may be unroofed, and the drainage fluid may be used for a Tzanck smear or direct antibody testing to confirm the diagnosis. Treatment consists of immobilization, elevation, and pain medication. Treat with antiviral agents such as acyclovir or valacyclovir for 1 week to abort recurrent infections and decrease the course of protracted cases 16 (Table 283-1). The finger should be kept in a clean dressing to prevent autoinoculation or spread of the herpes infection to other individuals.  NONINFECTIOUS INFLAMMATORY STATES OF THE HAND Noninfectious inflammatory states of the hand often present as an acute exacerbation of symptoms related to recent overuse. Inflammatory states of joints and tendons are painful and difficult to distinguish from acute septic arthritis or suppurative tenosynovitis. If the diagnosis is in doubt, treat for infection, and consult a hand specialist. If an inflammatory state is diagnosed, treat with rest, immobilization, elevation, and anti-inflammatory agents. TENDINITIS AND TENOSYNOVITIS Inflammatory tendinitis may involve the flexor or extensor tendons of the hand. Most often, the patient is able to recount a history of repetitive motion directly affecting the inflamed tendon. Palpation of the tendon produces tenderness. Active or passive movement of the tendon pro duces significant pain. Treatment is splinting in the position of function with elevation of the affected area and prescribing NSAIDs, with referral for care from the primary care physician or a hand surgeon. Remind patients to return to the ED for worsening pain, increased swelling, or any signs of infection, including fever and erythema.  TRIGGER FINGER Tenosynovitis can develop in the flexor sheaths of the fingers and thumb as a result of repetitive use. The ring finger and thumb are most frequently affected. 17 Scarring or inflammation may cause the tendon to become nodular, which results in friction and catching between the tendon and its sheath, usually in the vicinity of the A1 pulley at the volar crease at the base of each digit. The A1 pulley is the proximal portion of the tendon sheath. This is referred to as stenosing tenosynovitis or trigger finger. The patient experiences binding of the tendon, usually as the finger extends, relieved by a painful “snap” as the tendon nodule clears the first annular pulley.

crease at the base of each digit. The A1 pulley is the proximal portion of the tendon sheath. This is referred to as stenosing tenosynovitis or trigger finger. The patient experiences binding of the tendon, usually as the finger extends, relieved by a painful “snap” as the tendon nodule clears the first annular pulley. Occasionally, this condition may progress to the point that the finger locks, usually in flexion. Conservative treat ment includes rest, anti-inflammatory medications, and immobilization (buddy tape or finger split) to reduce inflammation and swelling of the flexor tendon sheath. Early stages of trigger finger have been treated successfully with corticosteroid injection into the tendon sheath. 18,19 If conservative treatment and steroid injection fail, surgical release of the A1 pulley is often curative.  DE QUERVAIN’S STENOSING TENOSYNOVITIS De Quervain’s tenosynovitis involves the extensor pollicis brevis and abductor pollicis tendons and occurs in patients who have experienced excessive use of the thumb or wrist. This condition is often associ ated with pregnancy, the postpartum period, and activities involving repeated radioulnar deviation such as hammering, cross-country skiing, or lifting a child. The patient presents with pain along the radial aspect of the wrist that may radiate to the thumb or extend into the forearm. The diagnosis of De Quervain’s tenosynovitis is supported by a history of pain in this location along with a painful range of motion of the thumb and local tenderness over the distal portion of the radial styloid. Further confir mation of the diagnosis may be provided by a positive Finkelstein test (Figure 283-6), in which the patient grasps the thumb in the palm of the hand and the examiner ulnar deviates the thumb and hand. This stretches the tendons over the radial styloid and produces sharp pain along the involved tendons. FIGURE 283-6. The Finkelstein test. The thumb is cupped in the closed fist, and ulnar deviation reproduces pain along the extensor pollicis and abductor pollicis. FIGURE 283-5. Herpetic whitlow. Note the cluster of vesicles on an erythematous base located at the distal finger. Tzanck smear is positive. [Photo contributor: Lawrence B. Stack, MD. Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ (eds): Atlas of Emergency Medicine, 3rd ed. New York, NY: McGraw-Hill, Inc.; 2010.] Tintinalli_Sec23_p1881-1932.indd 1918 8/2/19 3:16 PM

ematous base located at the distal finger. Tzanck smear is positive. [Photo contributor: Lawrence B. Stack, MD. Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ (eds): Atlas of Emergency Medicine, 3rd ed. New York, NY: McGraw-Hill, Inc.; 2010.] Tintinalli_Sec23_p1881-1932.indd 1918 8/2/19 3:16 PM CHAPTER 283: Nontraumatic Disorders of the Hand 1919 FIGURE 283-7. Dupuytren’s contracture. This chronic problem is seen at the most common site: the ring finger. [Photo contributor: Alan B. Storrow, MD. Reproduced with permission from Knoop KJ, Stack LB, Storrow AB, Thurman RJ (eds): The Atlas of Emergency Medicine, 3rd ed. New York, NY: McGraw-Hill, Inc.; 2010, Fig. 12-36.] FIGURE 283-8. A dorsal ganglion cyst. [Reproduced with permission from Simon RR, Sherman SC (eds): Simon’s Emergency Orthopedics, 7th ed. New York, NY: McGraw-Hill, Inc.; 2014.] Immobilize the thumb and wrist with a thumb spica splint or similar device. Instruct the patient to remove the splint briefly each day and perform range-of-motion exercises to prevent joint stiffness. In addition, start an anti-inflammatory medication for 10 to 14 days. Recurrence of this condition is common, particularly when related to occupational stress. Persistent cases may benefit from local corticosteroid injection or surgical decompression by a hand specialist. CARPAL TUNNEL SYNDROME Carpal tunnel syndrome is a peripheral mononeuropathy involving entrapment of the median nerve in the carpal canal or tunnel, which is covered by the tense transverse carpal ligament. Whenever a condition causes swelling in the carpal tunnel, the median nerve is compressed, causing paresthesias extending into the index and long fingers, the radial aspect of the ring finger, and along the palmar aspect of the thumb. Pain may also radiate proximally into the forearm or shoulder. The patient often complains of awakening at night with burning pain and tingling in the hand or numbness when driving a car or maintaining the wrist in prolonged flexion. Carpal tunnel syndrome may develop from traumatic, hematologic, rheumatologic, anatomic, and infectious causes. A common scenario is overuse, in which the patient recounts a history of repeated flexion and extension of the wrist. In addition, edematous conditions such as pregnancy and congestive heart failure may acutely exacerbate symptoms in patients with a predisposition for carpal tunnel syndrome. The final common pathway consists of a space-occupying lesion that increases intracanal pressures. As the pressure increases, perfusion of the epi neurium decreases, causing ischemia and nerve conduction block. Pain or paresthesia in the median nerve distribution suggests carpal tunnel syndrome and may be confirmed by electrodiagnostic testing. The median nerve sensory distribution is illustrated in Chapter 36, “Local and Regional Anesthesia, ” Figures 36-5 and 36-6. Two-point discrimination in this distribution is described as one of the most useful physical examination maneuvers for diagnosing carpal tunnel syndrome. 23 In addition, Tinel’s sign supports the diagnosis and involves tapping the volar aspect of the wrist over the median nerve. A positive sign produces paresthesias that extend into the index and long finger. Phalen’s sign is more sensitive and specific and involves flexing the wrist maximally and holding it in this position for at least 1 minute. 23 A positive test occurs when the patient complains of tingling and numbness along the median nerve distribution. Both tests are subject to falsepositive and false-negative results. The presence of median nerve motor deficit requires emergency hand consultation.

y and holding it in this position for at least 1 minute. 23 A positive test occurs when the patient complains of tingling and numbness along the median nerve distribution. Both tests are subject to falsepositive and false-negative results. The presence of median nerve motor deficit requires emergency hand consultation. Otherwise, initial treatment is a volar splint to maintain the wrist in neutral position coupled with anti-inflammatory medica tions for 10 to 14 days. Refer those with persistent symptoms to a hand surgeon for surgical decompression. Most patients have complete reso lution of their symptoms following surgical decompression, with around 5% requiring revision. DUPUYTREN’S CONTRACTURE Dupuytren’s contracture is a relatively common yet poorly understood disorder characterized by fibroplastic changes of the subcutaneous tis sues of the palm and volar aspect of the fingers. The fourth and fifth fingers are affected earliest. The condition is found most commonly in men of northern European descent. Dupuytren’s contracture is seen in those with tobacco use, alcoholism, diabetes mellitus, and repetitive handling or overuse. This progressive fibrosis eventually may lead to tethering and joint contracture (Figure 283-7). Firm longitudinal thickening and nodular ity of the superficial tissues over the distal tendon sheath of the palm are usually readily appreciated as the scarring process advances. The diagnosis is made by identifying a nodule in the palm, usually at the distal palmar crease of the ring or small finger, which is held in the classic flexion contracture. Refer to a hand specialist for surgical excision options. 26,27 GANGLION CYSTS A ganglion or synovial cyst is a cystic collection of synovial fluid within a joint or tendon sheath (Figure 283-8). It is common, often following an injury or repetitive microtrauma. Ganglion cysts arise from a herniation of synovial tissue from a joint capsule or tendon sheath. The patient presents with a tender cystic swelling over or near a tendon sheath. Common locations are the dorsal and volar wrist, flexor surface of the metacarpophalangeal joint, or the base of the nail. Involvement of the thumb may appear as generalized thumb pain, pain with movement, and edema. Treatment is pain control and anti-inflammatory medica tions. About one third of cysts resolve spontaneously, with referral to a hand surgeon for those with persistent or recurrent pain or cosmetic deformity. Treatment options include observation, cyst aspiration, or surgical excision. Surgical excision offers significantly lower chance of recurrence compared with aspiration. REFERENCES The complete reference list is available online at www.TintinalliEM.com. Tintinalli_Sec23_p1881-1932.indd 1919 8/2/19 3:16 PM