Development and Validation of a Prognostic, Risk-Adjusted Scoring System for Operative Upper-Extremity Infections


      Acute infections of the distal upper extremity (UE) can require one and possibly multiple debridements. We aimed to develop and validate a prognostic scoring system based on patient, infection, and microbiology risk factors to help with operative planning and patient counseling.


      We studied all acute surgical UE infections distal to the elbow joint over a 5-year period. A split-sample design was created with 1:1 randomization into development and validation samples. The primary outcome was infection persistence, defined as the need for additional operative drainage according to usual indications. Multivariable logistic regression identified risk factors for persistent infections in the development sample, which was translated to a simple clinical scoring system derived from regression coefficients. The model was then tested separately against the validation sample.


      A total of 602 patients were included; 31% of all infections exhibited persistence. Independent risk factors from the development sample included diabetes (3 points), smoking (2 points), leukocytosis at presentation (2 points), animal bite mechanism (3 points), osteomyelitis (4 points), tenosynovitis (7 points), pyarthrosis (3 points), necrotizing fasciitis (11 points), and methicillin-resistant Staphylococcus aureus (3 points). These were all confirmed in the validation sample. Infections were categorized into 3 groups based on risk for persistent infection: low (less than 8 points), medium (8–11 points), and high (12 points or more). In the validation sample, the probability of persistent infection for these 3 groups was 23%, 57%, and 79%, respectively. The c statistic for the model in the validation sample was 0.79.


      Persistence of acute surgical distal UE infections is mediated by patient and microbiology factors, as well as infection mechanism and type. Surgeons can use this risk-adjusted prognostic scoring system to anticipate which infections may require additional therapeutic debridement and plan operative schedules and counsel patients accordingly.

      Type of study/level of evidence

      Prognostic II.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Hand Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Verma R.
        • Foster R.E.
        • Horgan K.
        • et al.
        Lymphocyte depletion and repopulation after chemotherapy for primary breast cancer.
        Breast Cancer Res. 2016; 18: 10
        • McDonald L.S.
        • Bavaro M.F.
        • Hofmeister E.P.
        • Kroonen L.T.
        Hand infections.
        J Hand Surg Am. 2011; 36: 1403-1412
        • Ong Y.S.
        • Levin L.S.
        Hand infections.
        Plast Reconstr Surg. 2009; 124: 225e-233e
        • Simmen H.P.
        • Giovanoli P.
        • Battaglia H.
        • Wust J.
        • Meyer V.E.
        Soft tissue infections of the upper extremities with special consideration of abscesses in parenteral drug abusers: a prospective study.
        J Hand Surg Br. 1995; 20: 797-800
        • Stern P.J.
        • Staneck J.L.
        • McDonough J.J.
        • Neale H.W.
        • Tyler G.
        Established hand infections: a controlled, prospective study.
        J Hand Surg Am. 1983; 8: 553-559
        • Napolitano L.M.
        Severe soft tissue infections.
        Infect Dis Clin North Am. 2009; 23: 571-591
        • Kanavel A.B.
        Infections of the Hand.
        Lea & Febiger, Philadelphia, PA1921
        • Franko O.I.
        • Abrams R.A.
        Hand infections.
        Orthop Clin North Am. 2013; 44: 625-634
        • Osterman M.
        • Draeger R.
        • Stern P.
        Acute hand infections.
        J Hand Surg Am. 2014; 39: 1628-1635
      1. Mull AB, Sharma K, Yu JL, Hsueh K, Moore AM, Fox IK. Surgical upper extremity infections in immunosuppressed patients: a comparative analysis with diagnosis and treatment recommendations for hand surgeons [published online ahead of print July 23 2018]. Hand (N Y).

        • Sharma K.
        • Pan D.
        • Friedman J.
        • Yu J.L.
        • Mull A.
        • Moore A.M.
        Quantifying the effect of diabetes on surgical hand and forearm infections.
        J Hand Surg Am. 2018; 43: 105-114
        • Gonzalez M.H.
        • Bochar S.
        • Novotny J.
        • Brown A.
        • Weinzweig N.
        • Prieto J.
        Upper extremity infections in patients with diabetes mellitus.
        J Hand Surg Am. 1999; 24: 682-686
        • Gonzalez M.H.
        • Nikoleit J.
        • Weinzweig N.
        • Pulvirenti J.
        Upper extremity infections in patients with the human immunodeficiency virus.
        J Hand Surg Am. 1998; 23: 348-352
        • Gonzalez M.H.
        • Garst J.
        • Nourbash P.
        • Pulvirenti J.
        • Hall Jr., R.F.
        Abscesses of the upper extremity from drug abuse by injection.
        J Hand Surg Am. 1993; 18: 868-870
        • Fowler J.R.
        • Ilyas A.M.
        Epidemiology of adult acute hand infections at an urban medical center.
        J Hand Surg Am. 2013; 38: 1189-1193
        • Houshian S.
        • Seyedipour S.
        • Wedderkopp N.
        Epidemiology of bacterial hand infections.
        Int J Infect Dis. 2006; 10: 315-319
        • Tosti R.
        • Ilyas A.M.
        Empiric antibiotics for acute infections of the hand.
        J Hand Surg Am. 2010; 35: 125-128
        • O’Malley M.
        • Fowler J.
        • Ilyas A.M.
        Community-acquired methicillin-resistant Staphylococcus aureus infections of the hand: prevalence and timeliness of treatment.
        J Hand Surg Am. 2009; 34: 504-508
        • LeBlanc D.M.
        • Reece E.M.
        • Horton J.B.
        • Janis J.E.
        Increasing incidence of methicillin-resistant Staphylococcus aureus in hand infections: a 3-year county hospital experience.
        Plast Reconstr Surg. 2007; 119: 935-940
        • Tosti R.
        • Samuelsen B.T.
        • Bender S.
        • et al.
        Emerging multidrug resistance of methicillin-resistant Staphylococcus aureus in hand infections.
        J Bone Joint Surg Am. 2014; 96: 1535-1540
        • Allison D.C.
        • Miller T.
        • Holtom P.
        • Patzakis M.J.
        • Zalavras C.G.
        Microbiology of upper extremity soft tissue abscesses in injecting drug abusers.
        Clin Orthop Relat Res. 2007; 461: 9-13
        • Downs D.J.
        • Wongworawat M.D.
        • Gregorius S.F.
        Timeliness of appropriate antibiotics in hand infections.
        Clin Orthop Relat Res. 2007; 461: 17-19
        • Francel T.J.
        • Marshall K.A.
        • Savage R.C.
        Hand infections in the diabetic and the diabetic renal transplant recipient.
        Ann Plast Surg. 1990; 24: 304-309
        • Talan D.A.
        • Citron D.M.
        • Abrahamian F.M.
        • Moran G.J.
        • Goldstein E.J.
        Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group.
        N Engl J Med. 1999; 340: 85-92
        • Summanen P.H.
        • Talan D.A.
        • Strong C.
        • et al.
        Bacteriology of skin and soft-tissue infections: comparison of infections in intravenous drug users and individuals with no history of intravenous drug use.
        Clin Infect Dis. 1995; 20: S279-S282
        • Vittinghoff E.
        • McCulloch C.E.
        Relaxing the rule of ten events per variable in logistic and Cox regression.
        Am J Epidemiol. 2007; 165: 710-718
        • Mehta H.B.
        • Mehta V.
        • Girman C.J.
        • Adhikari D.
        • Johnson M.L.
        Regression coefficient-based scoring system should be used to assign weights to the risk index.
        J Clin Epidemiol. 2016; 79: 22-28
        • Nguyen D.T.
        • Graviss E.A.
        Development and validation of a prognostic score to predict tuberculosis mortality.
        J Infect. 2018; 77: 283-290
        • Rassi Jr., A.
        • Rassi A.
        • Little W.C.
        • et al.
        Development and validation of a risk score for predicting death in Chagas’ heart disease.
        N Engl J Med. 2006; 355: 799-808
        • Anderson L.M.
        • Magruder J.
        Split-Sample Strategies for Avoiding False Discoveries.
        Cambridge, MA: National Bureau of Economic Research, 2017
        • Heller R.
        • Rosenbaum P.R.
        • Small D.S.
        Split samples and design sensitivity in observational studies.
        J Am Stat Assoc. 2009; 104: 1090-1101
        • Kannel W.B.
        • Dawber T.R.
        • Kagan A.
        • Revotskie N.
        • Stokes III, J.
        Factors of risk in the development of coronary heart disease—six year follow-up experience. The Framingham Study.
        Ann Intern Med. 1961; 55: 33-50
        • Caprini J.A.
        Thrombosis risk assessment as a guide to quality patient care.
        Dis Mon. 2005; 51: 70-78
        • Knaus W.A.
        • Wagner D.P.
        • Draper E.A.
        • et al.
        The APACHE III prognostic system: risk prediction of hospital mortality for critically ill hospitalized adults.
        Chest. 1991; 100: 1619-1636
        • Zhang Z.
        • Zhang H.
        • Khanal M.K.
        Development of scoring system for risk stratification in clinical medicine: a step-by-step tutorial.
        Ann Transl Med. 2017; 5: 436
        • Weintrob A.C.
        Susceptibility to infections in persons with diabetes mellitus.
        (Available at:)
        • Kennedy S.A.
        • Stoll L.E.
        • Lauder A.S.
        Human and other mammalian bite injuries of the hand: evaluation and management.
        J Am Acad Orthop Surg. 2015; 23: 47-57
        • Abrahamian F.M.
        • Goldstein E.J.
        Microbiology of animal bite wound infections.
        Clin Microbiol Rev. 2011; 24: 231-246
        • Gordon R.J.
        • Lowy F.D.
        Pathogenesis of methicillin-resistant Staphylococcus aureus infection.
        Clin Infect Dis. 2008; 46: S350-S359
        • Sorensen L.T.
        Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review.
        Ann Surg. 2012; 255: 1069-1079
        • Arcavi L.
        • Benowitz N.L.
        Cigarette smoking and infection.
        Arch Intern Med. 2004; 164: 2206-2216
        • Chang R.
        • Wong G.Y.
        Prognostic significance of marked leukocytosis in hospitalized patients.
        J Gen Intern Med. 1991; 6: 199-203