Physiotherapy Management of Infection in Upper Limb

Raymond Tsang

13 March 2016

2

Hand Infection

In general, 3 phases for Assessment & Intervention for Physiotherapist:

• Acute Phase – acute inflammation & infection

• Post-Acute Phase – resolving inflammation & infection

• Post-Infection Phase – infection under control

3

Acute Phase

Assessment1. Acute Inflammation• Redness• Swelling• Temperature increase• Pain• Loss of function

4

Acute Phase

Assessment2. Wound Condition• 3-colour concept – red, yellow & black

wound• Any pus or abscess collection

5

Acute Phase

Intervention – Aims & Methods1. To minimize exacerbation of

inflammation & infection• Rest/immobilization (boxing glove

bandaging)• Compression (boxing glove

bandaging)• Elevation

6

Boxing Glove Bandaging

• Compression– venous return & oedema

• Reduction of inflammatory changes– rest– pain

• Facilitation of wound drainage

7

Elevation with sling suspension

8

Acute Phase

Intervention – Aims & Methods2. To prevent joint contracture• Rest/immobilization in intrinsic plus

position (position of immobilization)3. To drain pus and clean wound• Hibitane bath

9

Acute Phase

Intervention – Aims & Methods3. To drain pus and clean wound• Saline irrigation for deep wound• Whirlpool therapy (past)

10

Post-Acute Phase

Assessment1. Inflammation• Redness• Swelling• Temperature increase• Pain

11

Post-Acute Phase

Assessment2. Wound Condition• More healthy wound condition (with

the use of antibiotics debridement)• Pus or abscess collection

3. Joint ROM & Soft Tissue Adhesions

12

Post-Acute Phase

Intervention – Aims & Methods

1. To prevent/improve finger joint stiffness & soft tissue contracture

• Gentle active passive finger mobilization exercises

13

Post-Acute Phase

Intervention – Aims & Methods2. To prevent tendon adhesions &

improve tendon gliding• Tendon gliding exercises

14

Post-Acute PhaseIntervention – Aims &

Methods3. To reduce residual

swelling• Pneumatic compression

therapy• Massage• Bandaging; Coban wrap• Advice on continuing &

appropriate elevation

15

Intermittent Pneumatic Compression

(Lowe et al, 2005)16

Post-Infection Phase

Assessment1. Joint ROM & Joint Stiffness2. Soft Tissue Adhesions/Scars3. Residual Swelling4. Muscle Strength5. Pain6. Function

17

Post-Infection Phase

Intervention – Aims & Methods1. To improve finger joint ROM, stiffness

& soft tissue contracture• Active passive finger mobilization

exercises• Stretching

18

Post-Infection PhaseIntervention – Aims & Methods2. To improve soft tissue adhesions/Scars• Massage• Ultrasound therapy3. To improve tendon gliding• Tendon gliding exercises4. To muscle strength• Muscle strengthening exercises

19

Post-Infection Phase

Intervention – Aims & Methods5. To improve functions• Dexterity training• Work conditioning/simulation

programme

20

Common Infection Cases• Paronychia – infection of space surrounding

eponychial fold

21

Common Infection Cases• Felon – infection of closed space of volar

digital pulp

Septa22

Common Infection Cases• Felon

Treatment – Incision and drainage; appropriate antibiotics; open drainage of wound – saline gauze packing

23

Common Infection Cases• Infective Tenosynovitis

(Tubiana et al, 1996) Incision & Continuous Drainage

24

Common Infection Cases• Infective Tenosynovitis

25

Special Infection Cases

• Mycobacterial Infections– Typical: Mycobacterium Tuberculosis– Atypical:

(Bhambri et al, 2009)

26

M. Marinum

(Bhambri et al, 2009)

27(Cheung et al, 2010)

M. Marinum

28

Postoperative immobilization in boxing glove bandaging for 3 weeks

(Cheung et al, 2010)

M. Marinum

Drug Treatment (QMH)(1) Standard regimen for previously untreated patient.• Ethambutol and rifampicin(2) For patient with relapse after treatment• Clarithromycin and minocycline and ethambutolDuration of treatment• 6 month in total or at least 2 more months after definite clinical

improvementDosage• Ethambutol 15mg/kg QD daily• Rifampicin 450mg (for BW ≤ 50kg) or 600mg (for BW > 50kg) QD

daily• Clarithromycin 500mg BD daily• Minocycline 100mg BD daily

29 30

Other Mycobacterial Infections

• Drug Treatment – multi-drug therapy, e.g.:– Isoniazid– Pyrazinamide– Rifampicin– Ethambutol (risk of blurred vision, red / green

colour blindness)– Clarithromycin– Minocycline (risk of pigmentation)– Amikacin (risk of vestibular & auditory damage)

• Monitoring of drug compliance and side effects by physiotherapist

31

Mycobacterial Infections

• Monitoring of liver and renal functions, haemotological status (platelet, WBC, RBC counts)

32

Special Infection Cases

• Fungal Infections• Necrotising Fasciitis

33

Fungal Infection• Scedosporium apiospermum infection

34

Fungal Infection

35

Fungal Infection

Management• Multiple surgical debridements + bone

graft + percutaneous K-wire fixation• Prolonged drug treatment –

Itraconazole• Physiotherapy & Occupational Therapy

36

Necrotising Fasciitis• Type I – anaerobic bacteria and

streptococci other than serogroup A• Type II – group A Streptococci• Usually occurred in patients with

chronic debilitating diseases – diabetes, alcohol abuse, or renal insufficiency

(Cheung et al, 2009)

37

Necrotising FasciitisManagement• Prompt diagnosis with radical

debridement amputation• Appropriate antibiotics• Rehabilitation – management of

sequelae

38

Case 1

History• 88 year-old man• Slip & fell with sprained (R) Index

Finger• Consulted bonesetter• Developed swelling & pain for 3-4 days

before admission

39

Case - Preop

40

Case - Preop

41

Case – I & D - Postop D4

C/ST: E. Coli, Streptococci; Bacteroides 42

Case - Physiotherapy

43

Case – Postop D7(Osteolytic change at tuft of distal phalanx)

44

Case – Post-Amputation D1

45

Case – Post-Amputation D20

46

Case – Post-Amputation D29

AROM: (R) IF MPJ: 00-800; PIPJ: 00-500 (700)

Hand Grip: (R) 5kgf; (L) 9kgf

47

Case 2• Infection in an immunocompromised patient

48

Case 2• Infection in an immunocompromised patient

49

Case 2• Infection in an immunocompromised patient

6 weeks later 50

Application ofBoxing Glove Bandaging

51

•Wrist in neutral or slight extension

•MPJ ~ 900

•IPJ ~ 00

•Thumb in palmar abduction

Position of Immobilization

52

Position of Immobilization

MPJs

– Collateral ligaments taut in flexion

- Joint capsule & volar plate loose

(Tubiana et al, 1996)

53

Position of Immobilization

IPJs – Joint capsule & volar plate are tight

(Tubiana et al, 1996)

54

Video on Boxing Glove Bandaging

55

Re-assessment after Application

• Check any subjective discomfort, e.g. too tight, throbbing sensation

• Observe capillary refill of nail bed or pulp

• Feel the resilience of bandaging for even pressure

56

Re-assessment when Boxing Glove Bandaging is removed

• Revise boxing glove bandaging when it is loosened

• Check any local pressure points (especially at PIPJs, wrist)

• Check any reduction in swelling or oedema– Wrinkles or creases

• Check position of finger joints

57

References• Bhambri S, Bhambri A, Del Rosso JQ (2009) Atypical

mycobacterial cutaneous infections. Dermatologic Clinics 27: 63-73.

• Cheung JPY, Fung B, Tang WM, Ip WY (2009) A review of necrotising fasciitis in the extremities. Hong Kong Medical Journal 15: 44-52.

• Cheung JPY, Fung BKK, Ip WY (2010) Mycobacterium marinuminfection of the deep structures of the hand and wrist: 25 years of experience. Hong Kong Medical Journal 15: 211-216.

• Lowe E, Smith , Nolan TP (2005) Mechanical modalities: traction and intermittent pneumatic compression. In: Michlovitz SL, Nolan TP (Eds) Modalities for Therapeutic Interventions, Philadelphia: F.A. Davis, 165-181.

• To MKT, Ho PL, Ip WY (2005) Scedosporium apiospermumcausing septic arthritis of the hand in an immunocompetent patient. Hong Kong Journal of Orthopaedic Surgery 9: 73-78.

• Tubiana R, Thomine J-M, Mackin E (1996) Examination of the Hand and Wrist, 2nd ed, London: Martin Dunitz.