Collar Button Abscess

• 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.

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.

A web-space abscess may develop from an infected callus on the volar side of the distal palm. The abscess may spread to the dorsal aspect of the space, resulting in a "collar button" abscess (Fig. 7-3).

Collar Button Abscess

Figure 7—3. Collar button abscess. Note infection extends from volar to dorsal area. This can result from a simple injury such as a stabbing from an indelible pen.

Table 7-1 Antibiotic Treatments

Infectious Organism Antibiotic of Choice

Table 7-1 Antibiotic Treatments

Infectious Organism Antibiotic of Choice

Pasteurella

Ampicillin, penicillin

Eikenella

Ampicillin, penicillin

Escherichia coli

First- or second-generation cephalosporin

Enterobacter

Aminoglycoside, cephalosporin

Pseudomonas

Aminoglycoside, cephalosporin

Serratia

Aminoglycoside, cephalosporin

Nonsurgical Treatment

For superficial cellulitis, IV antibiotics are used. If infectious tenosynovitis is diagnosed within 24 to 48 hours of onset of symptoms, it may be treated with antibiotics, splinting, and hand elevation. Operative treatment is usually required.

Antibiotic treatments are described in Table 7—1. The digits can keep a flexed posture because of involvement of the tendon sheath from time to time.

Surgical Treatment

Treatment for a collar button abscess involves prompt surgical drainage. When an hourglass abscess is present, it requires both volar and dorsal incisions. We also make sure that no incision is placed transversely across the web space because of subsequent scar contraction and resulting full-finger abduction. Several different incisions have been advocated for the palmar incision.

Incision is begun just proximal to the ulnar end of the proximal flexion crease of the radial digit of the two involved fingers (Fig. 7-4A), and continued proximally and ulnarward, stopping just distal to the midpalmar crease overlying the meta-carpal of the ulnar digit involved. After the skin is divided, the subcutaneous tissue is spread with a clamp until any purulent material is encountered. The abscess is enlarged longitudinally. The surgeon applies compression from the dorsum web space while the wound is retracted. Increased drainage can be seen in the depth of the wound if there is a deep collar button abscess.

A second incision is made on the dorsum of the infected hand. This incision begins at the level of the metacarpophalangeal (MP) joints (Fig. 7-4B). It lies between the metacarpals and is extended distally in a straight line to end at the base of the involved web for a distance of 1 to 1.5 cm. The deep tissues are divided in a plane toward the palmar abscess. When the dorsal collection is entered, the opening is enlarged in the direction of the wound. After the infection has been evacuated and the wound irrigated, drains, made of gauze wicks, are placed into both wounds. The hand is dressed in a compressive dressing with a plaster splint; this is removed in 48 to 72 hours and soaks are started with a supervised hand therapy program. Active motion is encouraged.

Alternative Technique

The palmar surface approach is made with a zigzag incision starting just proximal to the web and stopping just distal to the midpalmar crease (Fig. 7—4C). The flaps are

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Responses

  • Tuula
    What is hand collar button abscess?
    5 years ago

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