November 8, 2020
This case report provides a unique perspective in managing a wound unlike any other.
Patient presented with an open wound at the clinic after surgery. Surgeon informed us that the surgery was done to remove a wart.
History: Patient was seen at the primary care to get a wart in the palm burnt. On doing so more warts showed up. He was then referred to a hand surgeon. Surgery was schedule to remove the wart at the level of A1 pulley of left middle finger.
The surgeon was surprised to see the wart present with a crumbling dirt like appearance that went deeper into the palm and had spread in the palm. He retrieved as best as he could and sent the culture to the lab. He could not close the wound as the cause was unknown and due to the presence of a gaping hole.
The patient was then referred to us which was oozing purulent exudate.
We started packing with saline impregnated gauze to close the wound from within and then cover with an absorbent dressing to soak the excessive exudate.
We almost got the wound closed but the cultures didn’t grow so they had to go back in, dig deeper to get some more cultures so that the warts do not come back.
Nontuberculous Mycobacterial Infections of the Upper Extremity: 15-Year Experience at a Tertiary Care Medical Center – David Sotello, MD,* Hillary W. Garner, MD,† Michael G. Heckman, MS,‡ Nancy N. Diehl, BS,‡ Peter M. Murray, MD,§ Salvador Alvarez, MD*
Since the cultures didn’t grow, the doctors could not put him on antibiotics to kill the virus completely. So, they decided to go back in deeper to get more samples to effectively treat the problem.
Patient had another surgery and then returned to therapy a day after
In the next few days the patients started to show signs of infection especially the way he had wrapped it. Surgeon was informed but he said the dressing was too tight and could be that. Over the weekend the patients hand swelled up and he ended up in the emergency room with obvious signs of infection. He was placed on basic antibiotics and sent home.
He returned with a completely macerated wound. The wound was debrided and aired to allow for skin to heal and patient was asked to change dressing 3x day due to the amount of discharge that was creating the maceration.
He then started to ooze pus and had to be drained out each visit
We were finally at a point where the wound was closing again.
One morning patient was treated with PROM and then FDS/ FDP was added. After 5 reps of FDS we performed FDP and then went back to FDS and FDS would not function. Surgeon was informed that the FDS may have ruptured. But FDP was still intact.
They found out that the patient was resistant to all antibiotics. They still did not know what the growth was and he was still not put on the correct antibiotics.
The infectious disease doctor could not confirm the diagnosis.
Patient returned the day after and non of the tendons were functioning. Both the tendons were eaten up by infection.
Surgeon was informed, who suggested that the patient go to the ER and get an emergency MRI. The MRI revealed rupture of both tendons, that evening he had the 3rd surgery to remove both FDS/ FDP tendons. Sutures were placed sporadically to let the wound ooze. Patient returned the after the weekend – see video below
They decided since they still hadn’t figured out the root cause and didnt have the infection in control to forgo the 2 stage tendon repair.
My job as the therapist was to get the wound closed, get passive ROM and buddy strap the finger so that the patient can use the hand again.
We took care of almost all the wounds, including the eschar that developed in the palm since the sutures were spaced out.
The patient is still in therapy at present and this is what he looks like right now
I will update his final result on discharge.
The entire process started on Sept 1st, initially we were only seeing him 3 days a week but soon realized he needed to come in 5 days a week, so we did that for a few weeks, and then tapered him back to 3 days a week when the pus happened and later rupture of the tendons.
He is now 2 days a week, to finally close the wound, get his ROM and make him as functional as he can
He has a hand based night functional splint to keep his MP’s in flexed position and day buddy loops.
This was one of the most interesting cases i have seen. It taught me a lot and so i decided to share the progress captured in pictures and videos.
To view all wound care videos or to learn how to perform wound care please click here
Please feel free to contact me with questions you may have.
Saba Kamal, OTR, CHT