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Web-Space Infections
Kevin D. Plancher
History and Clinical Presentation
A 32-year-old right hand dominant woman complains of increased pain in her right hand with swelling and redness, and is worried because her fingers are spreading apart. She said she stabbed herself with a pencil last week and does not remember a lot of pain or bleeding at the time of the injury. She does remember seeing a puncture wound on her hand that turned into a small blister and then a callus. She did not seek any medical help at that time and is now concerned because of the pain and appearance of her hand. She does not have diabetes and is not allergic to any medications.
Physical Examination
The patient is comfortable moving her hand but has pain when removing her hand from her jacket sleeve. She has obvious swelling of her second web space and distal to her distal palmar crease. The swelling is more pronounced on the palmar aspect but is still seen dorsally in the second web space. She has some abduction of her index finger at rest and is able to flex and extend her fingers actively but reports generalized pain in her palm. She has fluctuance and tenderness of the web space and cellulitis of the distal hand and forearm (Fig. 7–1). Her hand and all digits have no signs of vascular compromise.
Figure 7–1. (A) Hand with edema over second dorsal web space held in position of minimal pain. (B) Hand with extensive swelling happens often after neglect from what was thought to be a simple injury.
PEARLS
- Two incisions used to clear infections
- Recurrence can be avoided with early diagnosis when cellulitis is present. Rule out flexor tenosynovitis
- Collar button abscess should always be suspected if there is tissue reaction out of all proportion to the size of the superficial component of the abscess.
PITFALLS
- Lack of recognition of collar button access
- Inadequate drainage and dissection
- Avoid local anesthetic block to ensure deep debridement
- Flaps to open wounds should not be shallow to avoid flap necrosis.
Figure 7–2. Classic pain on extension of a digit with fusiform swelling and tenderness in patients with flexor tenosynovitis.
Kanavel’s sign was used to distinguish a deep infectious tenosynovitis from a superficial cellulitis although pain with finger extension was present in this patient (Fig. 7–2).
Diagnostic Studies
Posteroanterior and lateral radiographs of the hand do not identify any foreign objects and no bone or soft tissue abnormalities.
Differential Diagnosis
Pyoderma gangrenosum
Gout
Volar web-space infection
Diagnosis
Second interdigital web-space infection resulting in a collar-button abscess.
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