| A palmar abscess is an abscess deep within the tissues of the palm of the hand. An abscess is a localized infection, usually bacterial, that has been walled off by a protective lining called a pyogenic membrane. The abscess is a defense mechanism designed to prevent the spread of the infecting organism to other parts of the body. It is made up of destroyed tissue cells, white blood cells (leukocytes) carried to the area to fight the infection, and microorganisms (dead and alive).
Palmar abscess usually occurs because of an injury that allowed microorganisms to enter deep tissues of the palm and multiply. Microorganisms enter through a deep puncture wound; injury from a high-pressure paint, staple, or grease gun (high-pressure injection injury, or HPI injury); or spread of infection from a nearby structure (e.g., fingers). The infecting organism may also be transported through the bloodstream (hematogenous spread) to the hand. Blisters on the palm can allow microbes to penetrate to deeper tissues.
An abscess can occur in any of the compartments formed by the complex array of bones, joints, tendons, and nerves that make up the hand. A finger web space abscess that involves both the palm and top of the hand is called a collar button abscess. An abscess on the palm near the little finger is called a mid-palmar space abscess, and one near the thumb is a thenar space abscess.Risk: Palmar abscess is a rare but serious infection. Individuals working with their hands in a dirty environment (e.g., construction workers, landscapers, mechanics) are at higher risk for palmar abscess. Young men who are new to a job requiring the use of a paint, staple, or grease guns are at a higher risk of high-pressure injection injuries to the hand, which involve the left (usually nondominant) hand twice as frequently as the right hand (Rowse 118). |
Source: Medical Disability Advisor
| History: There may be a recent history of injury to the hand. The individual may complain of intense, throbbing pain and swelling of the palm. Physical exam: The exam reveals tense swelling, redness (erythema), and tenderness. There may be evidence of injury to the hand or the presence of blisters. The individual may have limited range of motion in the hand. Hand movement increases pain. Through pressing and manipulating the fingers, the examiner inspects the hand for Kanavel's four signs: finger(s) in a partially closed (flexed) position, pain on straightening (extension) the finger(s), swelling of the finger(s), and tenderness. Tests: Samples of pus and possibly blood should be cultured to identify the causative organism(s). Antibiotic sensitivity tests may be performed to determine the optimal drugs for treatment. Plain x-rays and ultrasound exams may also be administered. |
Source: Medical Disability Advisor
| The individual elevates the hand, and motion is restricted (immobilization). Local anesthesia is used. The abscess is cut and drained (incision and drainage) and irrigated with an antibiotic solution. At the discretion of the surgeon, treatment may involve the temporary placement of a tube (catheter) into the palm incision and a wick into the incision at the top of the hand to allow for irrigation (closed suction irrigation) of the abscess space. This technique is used less frequently, however, because it is labor-intensive, requires hospitalization, and causes discomfort.
Palmar abscess is treated with oral antibiotics. Hospitalization for observation and to administer intravenous antibiotics may be required for individuals with a suppressed immune system (those with AIDS or certain cancers), diabetes, a history of splenectomy (asplenia), an infection unresponsive to outpatient treatment, bloodstream infection (sepsis), or involvement of a joint, tendon, or bone. A tetanus vaccination may be administered. Finger amputation may be required for individuals with a severe high-pressure paint injection injury originating at a finger. |
Source: Medical Disability Advisor
| Full resolution of the infection should result using standard treatment with oral or intravenous antibiotics, incision and drainage with irrigation, elevation, and immobilization of the hand.
The hand should recover full function, but there may be permanent disability if tissue death (necrosis) caused damage to muscles or nerves. Up to 48% of HPI injuries result in amputation of the finger, and HPI injuries from use of tools that generate pressures exceeding 7000 psi are associated with an amputation rate of 100% (Rowse 116-117, 120). |
Source: Medical Disability Advisor
| Individuals with palmar abscess require rehabilitation to regain hand and wrist function. Outpatient therapy should begin 3 times a week for 6 to 8 weeks once the abscess is excised and the infection eliminated. An occupational therapist or physical therapist who is also a certified hand therapist should see the individual.
Therapy first addresses pain control and the reduction of swelling. Individuals learn to elevate the hand so that it rests above the elbow on a pillow to decrease swelling in the hand. Therapists may also perform retrograde massage, in which swelling is manually drained from the hand by massaging from the hand toward the direction of the shoulder. Therapists perform scar massage to promote healing and scar mobility over the surgical site. Cold may be applied to reduce swelling after exercise. Individuals may also need to perform desensitization exercises in order to prevent hypersensitivity to different stimuli.
Therapists teach stretching techniques to increase range of motion at the wrist and forearm. Initially, therapists may passively stretch the wrist and the forearm to increase flexion and extension, and increase rotation. They may also passively stretch the individual's fingers into flexion and extension. After the first few sessions, the individual should be actively stretching.
Strengthening exercises help restore function. The therapist guides the individual in strengthening wrist flexion and extension and forearm rotation, as well as in restoring hand strength. Individuals learn functional exercises and perform exercises that emphasize dexterity. |
Source: Medical Disability Advisor
| The presence of more than one infectious agent will complicate treatment. Tissue death (necrosis) can occur. The infection may spread locally and involve more of the hand. It may also spread into the bloodstream, causing a generalized sepsis and the possible infection of other structures. |
Source: Medical Disability Advisor
| Individuals will be unable to lift and carry heavy or bulky objects, operate equipment, or perform other tasks that require the use of both hands. Individuals who operate a telephone may need to use a headset. If the dominant hand is affected, the individual may be unable to write legibly, to type well, or to perform fine motor skills such as those needed to work in a laboratory. Such individuals may require a temporary or permanent reassignment of duties. Other restrictions and accommodations resulting from temporary or permanent limited use of one hand depend on specific job responsibilities. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Does individual have any risk factors, such as working with hands in a dirty environment or using a high-pressure paint or grease gun?
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Has individual reported a recent injury to the hand?
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Was there intense throbbing pain with swelling?
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Was there evidence of an injury or the presence of blisters or calluses?
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Was movement painful with limited range of motion? Was the area red and swollen?
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Was a culture and sensitivity of the affected area done? If necessary, were blood cultures performed?
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Were x-rays and ultrasound performed?
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Were conditions with similar symptoms ruled out?
Regarding treatment:
- Was incision and drainage done?
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Is individual on oral antibiotics? Did individual respond to treatment?
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Was hospitalization necessary?
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Was amputation necessary?
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Did individual receive a tetanus booster?
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Did other structures such as joints become involved? Was there any muscle or nerve damage?
Regarding prognosis:
- Is individual active in physical therapy? Does the therapist specialize in the treatment of the hand? Is a home exercise program in place?
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Can individual's employer accommodate any necessary restrictions?
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Is the affected hand dominant or nondominant?
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Does individual have any conditions that may affect ability to recover?
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Does individual have any complications such as multiple infecting organisms?
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Did individual develop sepsis or infections in other structures?
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Source: Medical Disability Advisor
| Rowse, D., and E. A. Emmett. "Solvents and the Skin." Industrial Solvents and Human Health. Eds. Scott D. Phillips and Gary R. Krieger. Philadelphia: W.B. Saunders, 2004. |
Source: Medical Disability Advisor
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