Hand Surgery Source

THENAR ABSCESS (INFECTION, THENAR SPACE)

Introduction

The thenar space is a bursa (potential space) extending radially from to the midpalmar septum to the thenar eminence. It lies between the adductor pollicis muscle and the index-finger flexor tendons. Infections of this space are usually due to gram-positive Staphylococci, and the presence of methicillin-resistant Staphylococcus aureus (MRSA) should be considered1.

Pathophysiology

  • Infection can result from direct bacterial inoculation (particularly of skin flora) through a puncture wound or by spread from adjacent spaces, particularly those of the index finger and the forearm.1,2

Related Anatomy

  • Adductor pollicis
  • Index finger
    • First web space
    • Flexor tendon sheath
  • Radial bursa

Incidence and Related Conditions

  • Thenar abscesses are uncommon but serious. They may cause, or be due to, infections in adjacent spaces of the hand, including suppurative tenosynovitis of the index finger, thumb and radial bursitis

Differential Diagnosis

  • Cellulitis
  • Necrotizing fasciitis
  • Radial bursitis
ICD-10 Codes

INFECTION, THENAR SPACE

Diagnostic Guide Name

INFECTION, THENAR SPACE

ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

DIAGNOSIS SINGLE CODE ONLY LEFT RIGHT BILATERAL (If Available)
INFECTION, THENAR, HYPOTHENAR, MIDPALMAR SPACE, CUTANEOUS ABSCESS   L02.512 L02.511  

ICD-10 Reference

Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Thenar Space Infection
  • Thenar Space Infection: Note arrow pointing to thumb flexor tendon sheath distally and second arrow at thenar space area.
    Thenar Space Infection: Note arrow pointing to thumb flexor tendon sheath distally and second arrow at thenar space area.
Pathoanatomy Photos and Related Diagrams
Thenar Space Diagrams
  • The thenar space borders are the index flexor sheath and the adductor pollicis fascia. Infection can spread here from the index or thumb flexor tendon sheaths or from puncture wounds.
    The thenar space borders are the index flexor sheath and the adductor pollicis fascia. Infection can spread here from the index or thumb flexor tendon sheaths or from puncture wounds.
  • Note the thenar space and its relationship to the radial bursa and flexor sheaths of the thumb and index finger.
    Note the thenar space and its relationship to the radial bursa and flexor sheaths of the thumb and index finger.
Symptoms
History of a puncture wound in the thenar area
Throbbing pain around base of thumb
Fever and chills
Swelling at base of thumb in area of thenar muscles
Typical History

Patients will typically present after the infected hand has become swollen and painful, some days after a puncture wound to the radial side of the palm.  Kanavel signs maybe present in the thumb and/or index finger.  A thenar space infection is an abscess and will require a surgical incision and drainage.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • Control the infection
  • Regain and preserve function of the hand
Conservative
  • Treatment by antibiotics alone, without surgical drainage and debridement, is unlikely to be effective unless the diagnosis is actually cellulitis without an abscess.
Operative
  • Incision and drainage, irrigation, and debridement as needed, followed by appropriate antibiotics.1
  • A 2014 review2 recommended the following first-line antibiotics (before obtaining culture-specific recommendations) for hand abscesses:
    • Ampicillin/sulbactam + vancomycin
    • Cefazolin + vancomycin
    • Clindamycin if severe penicillin allergy
  • An infectious disease consult is wise for these rare infections especially for resistant organisms and when multiple organisms are identified.
  • The table provides a list of potential antibiotic choices based on the infectious organism.2

 

Organism

Antibiotic

Methicillin-sensitive

Staphylococcus aureus

Cephalexin, amoxicillin clavulanate (PO)

Methicillin-resistant

Staphylococcus aureus

Trimethoprim/sulfamethoxazole (PO), linezolid (PO or IV)

If sulfa allergy, clindamycin or doxycycline

Vancomycin (IV), daptomycin (IV)

Quinupristin/dalfopristin (IV)

Tigecycline (IV)

Ceftaroline (IV)

Vancomycin-resistant

Enterococci

Daptomycin, linezolid (PO or IV), tigecycline (IV),

quinupristin/dalfopristin (IV)

Gram negative

Piperacillin/tazobactam

Ceftriaxone

Ertapenem

Quinolones/ciprofloxacin

Pseudomonas

Piperacillin/tazobactam

Cefepime

Meropenem

Anaerobic infections

Ampicillin/sulbactam, Piperacillin/tazobactam,

Ertapenem, meropenem

Metronidazole

Clindamycin

Tigecycline

Vibrio vulnificus

Ceftriaxone and doxycycline

Imipenem and doxycycline

Nocardia

Trimethoprim/sulfamethoxazole

If sulfa allergy: imipenem, ceftriaxone, amikacin

Sporothrix schenckii

Itraconazole

fluconazole and voriconazole

Mycobacterium marinum

Clarithromycin/azithromycin

Trimethoprim/sulfamethoxazole minocycline

Ethambutol

Aeromonas hydrophilia

Ciprofloxacin

Imipenem

Trimethoprim/sulfamethoxazole
Treatment Photos and Diagrams
Thenar Space Infection Treatment
  • Thenar Space Infection and thumb flexor sheath surgical treatment.
    Thenar Space Infection and thumb flexor sheath surgical treatment.
Complications
  • Stiffness
  • Spread of infection to adjacent spaces such as the first web
  • Osteomyelitis
  • Septic joints
  • Amputation
Outcomes
  • Recent outcome data are not available for this rare infection.
Key Educational Points
  • Detailed culture analyses of the infecting organism(s) are imperative for determining the optimal antibiotic treatment.
  • An infectious disease consult is wise for these rare infections especially for resistant organisms and when multiple organisms are identified.
References

Cited

  1. Rigopoulos N, Dailiana ZH, Varitimidis S, Malizos KN. Closed-space hand infections: Diagnostic and treatment considerations. Orthop Rev (Pavia) 2012;4(2):e19. PMID: 22802987
  2. Osterman M, Draeger R, Stern P. Acute hand infections. J Hand Surg Am 2014;39(8):1628-35. PMID: 25070032

New Articles (within the past 3 years)

  1. Marvel BA, Budhram GR. Bedside ultrasound in the diagnosis of complex hand infections: A case series. J Emerg Med 2015;48(1):63-68. PMID: 25315997
  2. Patel DB, Emmanuel NB, Stevanovic MV, et al. Hand infections: Anatomy, types and spread of infection, imaging findings, and treatment options. Radiographics 2014;34(7):1968-86. PMID: 25384296
  3. Osterman M, Draeger R, Stern P. Acute hand infections. J Hand Surg Am 2014;39(8):1628-35. PMID: 25070032

Reviews

  1. Patel DB, Emmanuel NB, Stevanovic MV, et al. Hand infections: Anatomy, types and spread of infection, imaging findings, and treatment options. Radiographics 2014;34(7):1968-86. PMID: 25384296
  2. Franko OI, Abrams RA. Hand infections. Orthop Clin North Am 2013;44(4):625-634. PMID: 24095077