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Hand trauma and herpes infection
HAND TRAUMA
AND HERPES INFECTION
I. F. S T A R L E Y and J. D. H O L M E S
From Aberdeen Royal Infirmary, Aberdeen, UK A herpes simplex type 2 infection of the hand after injury is described in a 26-year-old man. The management and implications of such an unusual hand infection are discussed.
Journal of Hand Surgery (British and European Volume, 1996) 21B: 5:681-682 Hand infections following trauma are well described, particularly when associated with the bacterial flora found in the human mouth such as staphylococci, streptococci and gram-negative bacilli, and the management of such injuries is a common problem faced by those dealing with hand injuries (Callaham 1988; Glass 1982; Hausman and Lisser, 1992; Moran and Talan, 1993; Phipps and Blanshard, 1992). Viral infection as a direct consequence of trauma to the hand is unusual but in this paper we describe a case of transmission of herpes simplex type 2 following a hand injury.
venous antiNotics and elevation, there was no improvement in the patient's general condition or in the condition of the hand. The sutures were removed, but the wound itself was unremarkable in appearance. There was no further improvement and 4 days after the original admission the wound was further explored under a general anaesthetic. At this time it was noted that although the wound was oedematous and inflamed there was no pus in the joint, but small lesions were noted over the dorsum of the middle finger. The wound was cleaned, laid open, irrigated and dressed daily. More lesions were noted on the fingers (Fig 1) and these were thought to be herpetic lesions. At this time the patient was started on intravenous acyclovir 200 mg five times daily. The clinical diagnosis of herpes was confirmed from viral swabs when herpes simplex type 2 was isolated from the wound. The patient's general condition and the condition of his hand improved greatly with the administration of the acyclovir. The wound was split skin grafted and the patient discharged home.
CASE R E P O R T
A 26-year-old right-handed man presented to his general practitioner with a hand injury sustained that day when he had punched another man in the mouth. The injury consisted of a 5 cm laceration over the dorsoulnar aspect of the MP joint of the right little finger. The finger was reported to have had a full range of movement initially. Exploration of the wound was performed under local anaesthetic by the general practitioner and found to extend down to the joint capsule. The tendons were intact and the wound was therefore cleaned and closed. The patient was discharged home and given flucloxacillin. On review the following day the wound was found to be clean and there was apparently no significant swelling. At 48 hours, however, there was marked swelling of the hand, the dorsum was inflamed and pus was found to be discharging from the wound. Referral was made at this time to the Regional Plastic Surgery Unit. On arrival, the patient was generally unwell and pyrexial. Erythema was seen over the whole of the dorsum of the hand and forearm. Movement of the fingers was painful and the range of movement was markedly reduced. There was otherwise no relevant physical findings. An X-ray showed a fracture involving the joint surface of the metacarpal of the little finger. Blood tests showed a haemoglobin of 16.3 g/l, platelets 155 x 109/1, Wbc 19.0 x 109/1, blood cultures were negative but wound swabs grew Streptococcus milleri. The hand was elevated and the patient started on intravenous antibiotics (cefuroxime and metronidazole). Under general anaesthesia the wound was explored and pus was found in the joint. The wound was cleaned thoroughly and very lightly sutured. The hand was put in a splint in the functional position. Over the next 48 hours in spite of continued intra-
DISCUSSION A punch to the mouth can produce a characteristic type of injury in which there is an incised wound over the knuckles. The joint is penetrated with heavy bacterial contamination and needs to be managed as a human bite. Viral contamination of such wounds is thought to be uncommon and would be expected to be due to viruses
Fig 1
681
Showing the incised wound over the little finger and the lesions on the middle finger.
682
found in the mouth, such as herpes simplex type 1, the common cold sore (Gill et al 1990, Mindel 1991; Walker et al 1990). In this case herpes simplex type 2 was isolated from the hand wound and no other sites. Herpes simplex type 2 is normally considered to be a genital infection, transmitted during sexual intercourse, with an incubation period of 2 to 20 days. During the primary infection, systemic manifestations due to a viraemia include malaise, fever and myalgia. Associated with these general symptoms are the development of painful papules or vesicles found at the primary source of contact, which in most cases is the genital area. These lesions then break down to form ulcers which crust and then heal spontaneously. The primary infection is usually the most severe and the disease is characterized by recurrent less severe episodes throughout life. Extragenital infection is rare, but oral, ocular and digital cases are described (Haburchak, 1978). In this case, with no previous history of either oral or genital herpes, it may be concluded that viral transmission occurred at the time of the initial injury. Hand infections following trauma, which fail to resolve with conventional management, should raise the possibility of viral infections of the wound (Norris, 1985). Although rare, the consequences of such infec-
T H E J O U R N A L OF H A N D SURGERY VOL. 21B No. 5 OCTOBER 1996
tions may be severe in terms of local and systemic effects unless identified early and appropriately dealt with. References C A L L A H A M M (1988). Controversies in antibiotic choices for bite wounds. Annals of Emergency Medicine, 17: 1321-30. G I L L M J, A R L E T T E J and B U C H A N K A (1990). Herpes simplex virus infection of the hand. Journal of the American Academy of Dermatology, 22: 111-116. GLASS K D (1982). Factors related to the resolution of treated hand infections. Journal of Hand Surgery, 7: 388-394. H A B U R C H A K D R (1978). Recurrent herpetic whitlow due to herpes simplex virus type 2. Archives of Internal Medicine, 138:1418 1419. H A U S M A N M R and LISSER S P (1992). Hand infections. Orthopedic Clinics of North America, 23:171 185. M I N D E L A (1991). Cutaneous herpes simplex infection. Scandinavian Journal of Infectious Diseases, Supplementum 78: 47-52. M O R A N G J and TALAN D A (1993). Hand infections. Emergency Medicine Clinics of North America, 11: 601-619. NORRIS R W (I985). An unusual band infection in a child remember herpes! Journal of Hand Surgery, 10B: 267-268. PHIPPS A R and BLANSHARD J (1992). A review of in-patient hand infections. Archives of Emergency Medicine, 9:299 305. W A L K E R L G, SIMMONS B P and LOVALLO J L (1990). Pediatric herpetic hand infections. Journal of Hand Surgery, 15A: 176 180.
Received: 24 November 1994 Accepted after revision: 1 April 1996 Mr I. F. Starley,Departmentof Plastic Surgery,Royal PrestonHospital, Sharoe Green Lane North, Fulwood, Preston PR2 9HT, UK. © 1996 The British Society for Surgery of the Hand
AND HERPES INFECTION
I. F. S T A R L E Y and J. D. H O L M E S
From Aberdeen Royal Infirmary, Aberdeen, UK A herpes simplex type 2 infection of the hand after injury is described in a 26-year-old man. The management and implications of such an unusual hand infection are discussed.
Journal of Hand Surgery (British and European Volume, 1996) 21B: 5:681-682 Hand infections following trauma are well described, particularly when associated with the bacterial flora found in the human mouth such as staphylococci, streptococci and gram-negative bacilli, and the management of such injuries is a common problem faced by those dealing with hand injuries (Callaham 1988; Glass 1982; Hausman and Lisser, 1992; Moran and Talan, 1993; Phipps and Blanshard, 1992). Viral infection as a direct consequence of trauma to the hand is unusual but in this paper we describe a case of transmission of herpes simplex type 2 following a hand injury.
venous antiNotics and elevation, there was no improvement in the patient's general condition or in the condition of the hand. The sutures were removed, but the wound itself was unremarkable in appearance. There was no further improvement and 4 days after the original admission the wound was further explored under a general anaesthetic. At this time it was noted that although the wound was oedematous and inflamed there was no pus in the joint, but small lesions were noted over the dorsum of the middle finger. The wound was cleaned, laid open, irrigated and dressed daily. More lesions were noted on the fingers (Fig 1) and these were thought to be herpetic lesions. At this time the patient was started on intravenous acyclovir 200 mg five times daily. The clinical diagnosis of herpes was confirmed from viral swabs when herpes simplex type 2 was isolated from the wound. The patient's general condition and the condition of his hand improved greatly with the administration of the acyclovir. The wound was split skin grafted and the patient discharged home.
CASE R E P O R T
A 26-year-old right-handed man presented to his general practitioner with a hand injury sustained that day when he had punched another man in the mouth. The injury consisted of a 5 cm laceration over the dorsoulnar aspect of the MP joint of the right little finger. The finger was reported to have had a full range of movement initially. Exploration of the wound was performed under local anaesthetic by the general practitioner and found to extend down to the joint capsule. The tendons were intact and the wound was therefore cleaned and closed. The patient was discharged home and given flucloxacillin. On review the following day the wound was found to be clean and there was apparently no significant swelling. At 48 hours, however, there was marked swelling of the hand, the dorsum was inflamed and pus was found to be discharging from the wound. Referral was made at this time to the Regional Plastic Surgery Unit. On arrival, the patient was generally unwell and pyrexial. Erythema was seen over the whole of the dorsum of the hand and forearm. Movement of the fingers was painful and the range of movement was markedly reduced. There was otherwise no relevant physical findings. An X-ray showed a fracture involving the joint surface of the metacarpal of the little finger. Blood tests showed a haemoglobin of 16.3 g/l, platelets 155 x 109/1, Wbc 19.0 x 109/1, blood cultures were negative but wound swabs grew Streptococcus milleri. The hand was elevated and the patient started on intravenous antibiotics (cefuroxime and metronidazole). Under general anaesthesia the wound was explored and pus was found in the joint. The wound was cleaned thoroughly and very lightly sutured. The hand was put in a splint in the functional position. Over the next 48 hours in spite of continued intra-
DISCUSSION A punch to the mouth can produce a characteristic type of injury in which there is an incised wound over the knuckles. The joint is penetrated with heavy bacterial contamination and needs to be managed as a human bite. Viral contamination of such wounds is thought to be uncommon and would be expected to be due to viruses
Fig 1
681
Showing the incised wound over the little finger and the lesions on the middle finger.
682
found in the mouth, such as herpes simplex type 1, the common cold sore (Gill et al 1990, Mindel 1991; Walker et al 1990). In this case herpes simplex type 2 was isolated from the hand wound and no other sites. Herpes simplex type 2 is normally considered to be a genital infection, transmitted during sexual intercourse, with an incubation period of 2 to 20 days. During the primary infection, systemic manifestations due to a viraemia include malaise, fever and myalgia. Associated with these general symptoms are the development of painful papules or vesicles found at the primary source of contact, which in most cases is the genital area. These lesions then break down to form ulcers which crust and then heal spontaneously. The primary infection is usually the most severe and the disease is characterized by recurrent less severe episodes throughout life. Extragenital infection is rare, but oral, ocular and digital cases are described (Haburchak, 1978). In this case, with no previous history of either oral or genital herpes, it may be concluded that viral transmission occurred at the time of the initial injury. Hand infections following trauma, which fail to resolve with conventional management, should raise the possibility of viral infections of the wound (Norris, 1985). Although rare, the consequences of such infec-
T H E J O U R N A L OF H A N D SURGERY VOL. 21B No. 5 OCTOBER 1996
tions may be severe in terms of local and systemic effects unless identified early and appropriately dealt with. References C A L L A H A M M (1988). Controversies in antibiotic choices for bite wounds. Annals of Emergency Medicine, 17: 1321-30. G I L L M J, A R L E T T E J and B U C H A N K A (1990). Herpes simplex virus infection of the hand. Journal of the American Academy of Dermatology, 22: 111-116. GLASS K D (1982). Factors related to the resolution of treated hand infections. Journal of Hand Surgery, 7: 388-394. H A B U R C H A K D R (1978). Recurrent herpetic whitlow due to herpes simplex virus type 2. Archives of Internal Medicine, 138:1418 1419. H A U S M A N M R and LISSER S P (1992). Hand infections. Orthopedic Clinics of North America, 23:171 185. M I N D E L A (1991). Cutaneous herpes simplex infection. Scandinavian Journal of Infectious Diseases, Supplementum 78: 47-52. M O R A N G J and TALAN D A (1993). Hand infections. Emergency Medicine Clinics of North America, 11: 601-619. NORRIS R W (I985). An unusual band infection in a child remember herpes! Journal of Hand Surgery, 10B: 267-268. PHIPPS A R and BLANSHARD J (1992). A review of in-patient hand infections. Archives of Emergency Medicine, 9:299 305. W A L K E R L G, SIMMONS B P and LOVALLO J L (1990). Pediatric herpetic hand infections. Journal of Hand Surgery, 15A: 176 180.
Received: 24 November 1994 Accepted after revision: 1 April 1996 Mr I. F. Starley,Departmentof Plastic Surgery,Royal PrestonHospital, Sharoe Green Lane North, Fulwood, Preston PR2 9HT, UK. © 1996 The British Society for Surgery of the Hand