Pip Joint Debridement

• Assume that joint swelling will resolve with elevation and conservative treatment (antibiotics)

• Avoid a small incision under local anesthesia rather than wide debridement and irrigation in an operating room under regional anesthesia.

• Never assume the type of infection until the labs and culture and sensitivities dictate the correct antibiotic treatment.

Differential Diagnosis

Gout

Psoriatic arthritis flare Systemic lupus erythematosus

Diagnostic Studies

Synovial fluid analysis includes Gram stain, cultures, and sensitivity testing. In septic arthritis, the joint fluid contains a white blood cell count over 50,000/mm3. The polymorphonuclear count should be over 75% and the synovial fluid glucose is 40 mg or lower.

Radiographs are taken to rule out an occult fracture and to assess the joint space for loose or foreign bodies. When treatment is been delayed, radiographs can be useful to determine the extent of articular cartilage destruction and bone loss.

Diagnosis

Pyogenic Arthritis Index Finger

Based on the clinical exam and the laboratory values of the synovial fluid, Gram stains, and cultures, the diagnosis of pyogenic arthritis was ruled in as the diagnosis. The most common organism isolated from septic hand joints is Staphylococcus aureus. Contamination of the joint can occur by several mechanisms including hematogenous or contiguous spread and postoperative infectious. Direct implantation of organisms can also occur from a hand injury during a brawl, or penetration from a nail, knife, etc. High suspicion for joint infection is important when the MP joints are involved. This is the case because these joints are the major target sites for lacerations secondary to coming in contact with human teeth during fistfights.

Nonsurgical Treatment

Because septic arthritis can cause articular cartilage destruction and osteomyelitis, aggressive surgical treatment is recommended. Nonsurgical treatment is not recommended for any open joint laceration that is suspected to have occurred from a bite or contact with a contaminated object.

Surgical Treatment

Once the diagnosis has been made (Fig. 6—1), the patient should be started on appropriate antibiotic (Table 6—1) and proceed with aggressive treatment of incision and drainage of the joint. This aggressive treatment is important to minimize the cartilage destruction and osteomyelitis.

Longitudinal Incision Bite
Figure 6—1. Swollen proximal interphalangeal (PIP) joint with pyogenic arthritis preoperative in another

patient.

Table 6-1 Antibiotic Choice Specific to Organism Treatment

Organism

Preferred Drug

Dosage

Staphylococcus aureus

Streptococcus spp. Haemophilus influenzae Pseudomonas aeruginosa Serratia spp. Pasteurella multocida

Eikenella corrodens

Neisseria gonorrhoeae Mycobacterium marinum

Cefazolin

Vancomycin (MCRS) Penicillin G Ceftriaxone Ticarcillin Ticarcillin

Ampicillin-sulbactam

(Unasyn) Ampicillin-sulbactam

(Unasyn) Ceftriaxone Ethambutol Biaxin

1 g IV q8h

500 mg IV q6h

2-4 million units IV q4h

1 g IV q12h

3 g IV q6h

3 g IV q6h

3 g IV q6h

3 g IV q6h

1 g IV q12h

2500 mg po q day X 6 months 500 mg po bid X 6 months

The procedure to drain the proximal interphalangeal (PIP) joint is to make a midaxial incision on either side of the joint that will allow adequate drainage (Fig. 6—2). Care should be taken to avoid injury to the neurovascular bundles. In the fingers, section the transverse retinacular ligament. The extensor lateral band is retracted dorsally, and the neurovascular bundle is retracted toward the palm. Once the collateral ligament is identified, a longitudinal incision is made parallel and palmar to the ligament, separating the accessory collateral ligament. A portion of the collateral ligament is removed and the joint is drained. The specimens are sent to the lab for aerobic and anaerobic cultures. The joint space must be copiously irrigated, and the fibrinous and synovial debris is debrided. The wound can be packed to allow for continuous bedside irrigation, or, if joint de-bridement has been adequate, the wound can be loosely closed. A bulky dressing is applied with a splint.

If the joint or bone has been destroyed, removal may be required. Antibiotic-impregnated spheres can be useful in reconstruction of the joint with arthrodesis or bone grafting once the infection has been eliminated. In severe cases, amputation may be required.

Pip Joint Fixation
Figure 6—2. Procedure to drain the PIP joint is to make a midaxial incision on either side of the joint that will allow adequate drainage.
Pip Joint Surgery
Figure 6—3. Alternative surgical approach to the PIP joint for exposure and joint debridement. Dorsal midline approach.

Alternative Treatment

An alternative surgical approach is the dorsal midline approach (Fig. 6—3).

Postoperative Management

It is important to keep the hand elevated for 24 hours following initial irrigation and allow the hand to rest so that the soft tissues do not swell. The bandage must be changed and checked for adequate drainage of the wound, or, rather, ensure that no fluid is collecting in the joint. As the wound calms down and dries up, the patient starts range-of-motion exercises. Wound checks should be continued. The appropriate antibiotics should be prescribed, and the patient must complete the full course of the treatment.

Complications

Narrowing of the MP and PIP joints after apyogenic infection is treated (Fig. 6-4).

Metacarpophalangeal Amputation

Figure 6—4. Radiograph of the metacarpophalangeal (MP) joint of the ring finger. This is three years after a previously septic joint. Anteroposterior (AP) view.

Figure 6—4. Radiograph of the metacarpophalangeal (MP) joint of the ring finger. This is three years after a previously septic joint. Anteroposterior (AP) view.

Suggested Readings

Boustred AM, Singer M, Hudson DA, Bolitho GE. Septic arthritis of the metacarpophalangeal and interphalangeal joints of the hand. Ann Plast Surg 1999;42: 623-628.

de Vries H, van der Werken C. Septic arthritis of the hand. Injury 1993;24: 32-34.

Harris PA, Nanchahal J. Closed continuous irrigation in the treatment of hand infections. J Hand Surg 1999;24B: 328-333.

Harth M, Ralph ED, Faraawi R. Septic arthritis due to Mycobacterium marinum. J Rheumatol 1994;21:957-960.

Hausman MR, Lisser SP. Hand infections. Orthop Clin North Am 1992;23:171-185.

Marinella MA. Group G streptococcal septic arthritis of an interphalangeal joint. Clin Exp Rheumatol 1996;14:577-578.

Murray PM. Septic arthritis of the hand and wrist. Hand Clin 1998;14:579-587.

Nemoto K, Yanagida M, Nemoto T. Closed continuous irrigation as a treatment for infection in the hand. J Hand Surg 1993;18B:783-789.

Rothe M, Rudy T, Stankovic P. Treatment of bites to the hand and wrist-is the primary antibiotic prophylaxis necessary. Handshir Mikrochir Plast Chir 2002;34: 22-29.

Tonta K, Kimble FW Human bites of the hand: theTasmanian experience. Aust NZ J Surg 2001;71:467-471.

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Responses

  • samsa
    What is interphalangeal joint debridement?
    7 years ago

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