Introduction
This topic covers phlegmon of the hand and forearm: diffuse acute suppurative inflammation of the subcutaneous, fascial and deep soft tissues of the palm, back of the hand and forearm. It is distinct from panaritium (topic 64), which is a localised infection of the finger itself, although a panaritium can be the source of a palmar or forearm phlegmon.
Definition and causes
A phlegmon is an acute purulent inflammation that spreads through loose connective tissue without a sharply defined capsule, in contrast to an abscess, which is a walled-off collection of pus. In the hand it is a surgical emergency because the tight fascial compartments, tendon sheaths and fascial planes allow infection to spread quickly and raise pressure within a confined space.
- Entry routes: puncture wounds, lacerations, bites (human and animal), injections (including intravenous drug use), splinters, burns, frostbite and cracked skin.
- Spread from a neighbouring focus: untreated panaritium, infected web-space wounds, or lymphatic spread from a distant site.
- Organisms: mainly Staphylococcus aureus and beta-haemolytic streptococci, often mixed; Gram-negative and anaerobic organisms are important in bites and in diabetic or immunocompromised patients.
- Predisposing factors: diabetes mellitus, immunosuppression, alcohol misuse, peripheral vascular disease and occupational hand trauma.