Hand Infections

Intravenous AntibioticsTetanus Toxoid Elevation of the Limb Posi Z-Splint (Position of Safe immobilisation Splint)

Initial Evaluation

  1. Discern between cellulitis, abscess or flexor synovitis. All three have different management protocols.
  2. Consider pseudogout or gout which can give similar presentation.
  3. Abscesses and infective flexor synovitis will require emergent surgical management.
  4. Request X-rays of affected part of limb.
  5. Consider ultrasound.
  6. Order baseline CRP, WCC and ESR.

Making a Diagnosis

  1. An abscess will show an area of fluctuation and is commonly associated with cellulitis. This requires surgical drainage.
  2. Flexor synovitis is another surgical emergency and is an infection of the synovial sheath of the flexor sheath. This infection can very rapidly spread up the forearm, especially if the thumb or the little finger is involved. The signs of Kanavel describe the signs of flexor synovitis: Fusiform swollen digit, redness along the flexor tendon tract, tenderness on palpation on the tract of the flexor sheath and pain on passive extension of the digit. This is a surgical emergency.
  3. Cellulitis is, per definition, an infection involving the dermal layer of the skin. There is usually a painful swollen limb, demarcated borders of erythema with or without lymphangitis or enlarged painful reactive lymph nodes.

Initial Management

  1. If it is an open wound, give tetanus prophylaxis.
  2. Start empiric Flucloxacillin (1g QID IVI in adults).
  3. Mark out cellulitic borders on the skin.
  4. Immobilise the limb in a POSI Z-splint.
  5. Elevate the limb in a pillow slip.
  6. Keep patients with stigmata of abscess or flexor synovitis fasted until a hand surgeon evaluates the patient.


  1. Commence mobilisation of the hand once the infection is under control.
  2. Splints are used to immobilise the hand in a safe position whilst the wounds and soft tissues are settling.
  3. Therapy will address oedema, scarring, limitation in range of movement and weakness in the hand, once the infection has settled.