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Phalanges. The 14 bones that are found in the fingers of each hand and also in the toes of each foot. Each finger has 3 phalanges (the distal, middle, and proximal); the thumb only has 2.

Numerous muscles, ligaments, tendons, and sheaths can be found within the hand. The muscles are the structures that can contract, allowing movement of the bones in the hand. The ligaments are fibrous tissues that help bind together the joints in the hand. The sheaths are tubular structures that surround part of the fingers. The tendons connect muscles in the arm or hand to the bone to allow movement.

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Acute hand infections are often caused by puncture wounds and are generally classified into superficial or deep infections. Superficial infections occur in the skin and subcutaneous tissues, whereas deep infections can involve the tendon sheaths, adjacent anatomic compartments, deep fascial planes, bursae, joint spaces, and bones. Superficial hand infections are more common than deep infections and are typically managed with elevation, warm soaks, splinting in the position of function, analgesics, and empiric antibiotics when indicated. Paronychia, which can be acute or chronic, is an infection or inflammation of the nail fold. Treatment involves warm soaks, topical antibiotics, and abscess drainage, if indicated. A felon is an infection of the distal pulp of the finger. Treatment often involves surgical drainage and empiric oral antibiotics. Herpetic whitlow is caused by herpes simplex virus and typically resolves without intervention. Deep hand infections include pyogenic flexor tenosynovitis and clenched-fist bite wounds. Pyogenic flexor tenosynovitis is a rapidly progressing bacterial infection of the flexor tendon sheaths in the hand, most commonly caused by a penetrating injury to the finger. Clenched-fist bite wounds result from direct contact of the fist on incisor teeth and are associated with polymicrobial infections. Empiric antibiotics and prompt surgical consultation are indicated to reduce long-term morbidity.

The hand can easily be injured during everyday activities. Any trauma to the hand, particularly a penetrating trauma, may introduce damaging pathogens. The hand's compartmentalized anatomy may contribute to the development of an infection, and if an infection is not appropriately diagnosed and treated, significant morbidity can result.

The anatomy of the hand allows infections to easily spread from the point of inoculation to deep structures, including tendon sheaths, adjacent anatomic compartments, deep fascial planes, bursae, joint spaces, and bones.40 Penetrating trauma often results in severe or rapidly progressing infections within deep structures of the hand. These infections are associated with significant morbidity and dysfunction if not recognized and treated early with surgical management and antibiotics.1,40 Two of the most common deep hand infections are pyogenic flexor tenosynovitis and clenched-fist bite wounds.

Pyogenic Flexor Tenosynovitis. Pyogenic flexor tenosynovitis is a closed-space infection of the flexor tendon sheath. It is most commonly caused by a penetrating injury to the finger. The flexor tendon sheaths in the hand typically span from the neck of the metacarpal to the distal interphalangeal joint, although there are many anatomic variations. Flexor tendon sheaths have a poor vascular supply and are filled with synovial fluid, which is a good medium for bacterial growth.3 Inoculation of bacteria into the synovial fluid causes increased pressure within the sheath, leading to impaired vascular flow, tendon necrosis, and ultimately, tendon rupture.16 Staphylococcus species, including methicillin-resistant S. aureus, and Streptococcus species are the most commonly identified pathogens,12 although approximately one-third of wound cultures show no growth, and gram-negative organisms are present in 10% of cases.2 Hematogenous spread to the tendon sheaths is less common and typically occurs only in immunocompromised patients.40

Because the fist is clenched during injury, teeth may damage deeper structures within the hand, resulting in fracture, joint capsule penetration, or extensor tendon damage29,55 (Figure 8). Older studies have shown that up to 75% of clenched-fist bite wounds result in tendon, bone, joint, or cartilage damage, whereas newer studies suggest that the incidence of joint capsule penetration may be higher, with 100% proximal interphalangeal joint involvement and 95% metacarpophalangeal joint involvement.55,56 Because of the high level of tendon, bone, and joint involvement, it is important that physicians recognize the potential for serious complications when managing clenched-fist bite wounds. Radiography should be obtained to evaluate for fracture, foreign bodies, and early signs of osteomyelitis.19 Neurovascular and musculoskeletal examinations should be performed, and Elson testing should be performed on each digit to evaluate extensor tendon function ( =wyHSKgAZ1eA).19

Initial wound management should include hemostasis, copious irrigation, removal of any foreign bodies, and debridement of necrotic tissue.19,29 The wound should be extended to inspect the joint capsule and extensor tendon mechanism.19,55 A tetanus booster and immunoglobulin should be administered, if indicated.19,24,29 Before initiation of empiric antibiotics, tissue should be obtained for Gram staining and aerobic and anaerobic cultures. Tissue cultures are preferred over wound cultures because of their improved accuracy.19 Wounds should be allowed to heal by secondary intent,19,20 and the hand should be splinted in a position of function and elevated.1

Data Sources: A PubMed search was conducted using the key terms acute hand infection, paronychia, felon, herpetic whitlow, flexor tendon synovitis, pyogenic tenosynovitis, human bite injury, clenched fist injury. The search included systematic and clinical reviews, meta-analyses, reviews of clinical trials and other primary sources, and evidence-based guidelines. Also searched were the Cochrane database, the National Institute for Health and Care Excellence guidelines, the Choosing Wisely Campaign, Essential Evidence Plus, Google Scholar, and UpToDate. References from these sources were consulted to clarify the statements made in publications. Search dates: November 2017 to November 2018.

A hand is a prehensile, multi-fingered appendage located at the end of the forearm or forelimb of primates such as humans, chimpanzees, monkeys, and lemurs. A few other vertebrates such as the koala (which has two opposable thumbs on each "hand" and fingerprints extremely similar to human fingerprints) are often described as having "hands" instead of paws on their front limbs. The raccoon is usually described as having "hands" though opposable thumbs are lacking.[1]

The human hand usually has five digits: four fingers plus one thumb;[3][4] these are often referred to collectively as five fingers, however, whereby the thumb is included as one of the fingers.[3][5][6] It has 27 bones, not including the sesamoid bone, the number of which varies among people,[7] 14 of which are the phalanges (proximal, intermediate and distal) of the fingers and thumb. The metacarpal bones connect the fingers and the carpal bones of the wrist. Each human hand has five metacarpals[8] and eight carpal bones.

Among humans, the hands play an important function in body language and sign language. Likewise, the ten digits of two hands and the twelve phalanges of four fingers (touchable by the thumb) have given rise to number systems and calculation techniques.

Many mammals and other animals have grasping appendages similar in form to a hand such as paws, claws, and talons, but these are not scientifically considered to be grasping hands. The scientific use of the term hand in this sense to distinguish the terminations of the front paws from the hind ones is an example of anthropomorphism. The only true grasping hands appear in the mammalian order of primates. Hands must also have opposable thumbs, as described later in the text.

The hand is located at the distal end of each arm. Apes and monkeys are sometimes described as having four hands, because the toes are long and the hallux is opposable and looks more like a thumb, thus enabling the feet to be used as hands.

The word "hand" is sometimes used by evolutionary anatomists to refer to the appendage of digits on the forelimb such as when researching the homology between the three digits of the bird hand and the dinosaur hand.[2]

There are five digits attached to the hand, notably with a nail fixed to the end in place of the normal claw. The four fingers can be folded over the palm which allows the grasping of objects. Each finger, starting with the one closest to the thumb, has a colloquial name to distinguish it from the others:

The thumb (connected to the first metacarpal bone and trapezium) is located on one of the sides, parallel to the arm. A reliable way of identifying human hands is from the presence of opposable thumbs. Opposable thumbs are identified by the ability to be brought opposite to the fingers, a muscle action known as opposition.

The skeleton of the human hand consists of 27 bones:[10] the eight short carpal bones of the wrist are organized into a proximal row (scaphoid, lunate, triquetral and pisiform) which articulates with the bones of the forearm, and a distal row (trapezium, trapezoid, capitate and hamate), which articulates with the bases of the five metacarpal bones of the hand. The heads of the metacarpals will each in turn articulate with the bases of the proximal phalanx of the fingers and thumb. These articulations with the fingers are the metacarpophalangeal joints known as the knuckles. At the palmar aspect of the first metacarpophalangeal joints are small, almost spherical bones called the sesamoid bones. The fourteen phalanges make up the fingers and thumb, and are numbered I-V (thumb to little finger) when the hand is viewed from an anatomical position (palm up). The four fingers each consist of three phalanx bones: proximal, middle, and distal. The thumb only consists of a proximal and distal phalanx.[11] Together with the phalanges of the fingers and thumb these metacarpal bones form five rays or poly-articulated chains. ff782bc1db