Lecture 8.
Acute suppurative diseases of the fingers (whitlow)
Problem treat whitlows, despite the long history remain relevant not only because of the frequency of disease (in Ukraine whitlow annually observed in 1% of the population). In practice surgeons so far kept the tradition of long-term use of conservative treatments, performing inadequate surgical approaches that provide only the evacuation of pus without adequate necrectomy. In some cases, purulent process is reduced and the wound heals, but the finger as functioning anatomical structure becomes unusable due to scar contracture and disorders of innervation.
Whitlow – an acute purulent inflammation of tissues finger or less feet. On the palmar surface of the finger skin combined with palmar aponeurosis tendon thick strands between which are the accumulations of adipose tissue. In inflammatory skin lesions or inflammation of injuries quickly spread along connective strands on deep tissue tendon, bone formation joints. Furthermore, accumulation of fluid in a closed cavity between connective tissue bridges leads to poor circulation due to compression of the supplying vessels and the rapid development of tissue necrosis.
Panaritium often occurs as a result of minor injuries palmar surface of the fingers in the home, at work, at least it is a result of disruption of burrs or microtraumas in manicure. Contributed to and protracted course panaritiums diabetes, chronic circulatory disorders. Causative agent of this disease is simple puss production organisms (staphylococci, streptococci). Atrium is small skin lesions (rapture, cracks, scratches). Often the cause of inflammation are foreign bodies (splinters, metal shavings).
Panaritiums classification: A. Surface shape – paronychia, subungual, cutaneous, subcutaneous, B. Deep shape – bone, joint, tendon, pandactylitis.
General characteristics and clinical presentation. There are several forms of whitlows. However, their clinical manifestations largely coincide. First of all, patients worried swelling and redness of the affected area of the finger. Body temperature may rise, with severe lesions significantly worse overall. Characteristic for whitlows is pulling, intense, constant pain.
Necessary to noted that due to the theme of anatomy brush the localization of abscess on the palmar surface of the finger, swelling and redness will be more pronounced on its rear surface.
Skin whitlow. Manure is located in the uppermost layers of the skin, destruct it. This forms a bubble filled with purulent or bloody fluid.
Subcutaneous whitlow. At closer inspection you caotice swelling and tension fabric finger located near interphalangeal creases. Redness dim.
Paronychia – inflammation paranail roll, accompanied by his painful swelling and redness of the surrounding tissues. On examination marked overhanging affected paranail roll over the nail plate. In some cases the pus can get under the nail. This fluid is glimpsed through the peeling of the nail.
Subungual whitlow – characterized by an accumulation of pus under the nail plate. With advanced process manure is seen at all or fingernail under one of its edges.
Articular whitlow – occurs more frequently after finger injury to the back surface of the joint. The pain is intense, skin furrows in the joint smoothed, the skin is red, because of the swelling of the finger becomes fusiform. Trying to bend the finger leads to a sharp increase in pain. In advanced cases, the joint is destroyed, can be formed fistula. Pain while slightly reduced, but the function of the finger is not restored. There unnatural mobility, crunching sensation in the area diseased joint.
Bone whitlow – or develops during the transition inflammation of soft tissue or bone by direct injury (injection sewing needle, chips, fish bone). In case the inflammation of the soft tissues surrounding the bone, after a period of apparent improvement complete recovery does not occur. The pain is constant aching iature, formatted fistula with purulent discharge meager. Finger whole gradually thickens, it functions completely lost.
Tendon whitlow – a purulent process in subcutaneous felons without proper treatment can spread to the flexor tendons of fingers. It comes significant deterioration. Throbbing, pulling pain spreads throughout the fingers. All finger along the length edema, skin red. Interphalangeal creases smoothed. Finger becomes like a sausage and slightly bent. This forced position reduces tendon tension and reduces pain.
Pandactylitis – purulent inflammation of all tissues of the finger. Proceeds hard, accompanied by headache, high body temperature. Growth nearest lymph nodes. Pandactylitis may develop as a result of injury to the finger, but more likely it is untreated simple forms felons. With the development pandactylitis pain becomes arching nature. Edematous finger blue-purple color. All fabrics are gradually drawn into the process and necrotizing. With fistulas or postoperative wounds flowing manure in small quantities. Touching finger sharply painful. Trying movement causes a sharp increase in pain. Further development of the pathological process leading to the spread of suppuration of the brush and then – the entire limb.
First aid. Whitlow is developing very fast. In the initial stages, when the toe area there is a feeling of pain when moving or clicking, you can try to stop the use of anti-inflammatory drugs, alternating warm saline bath with vodka dressing. All attempts at self-treatment or conservative treatment should be stopped when the appearance of constant tugging pain. Go to the doctor! There is a figurative expression that determines the timing of the operation: “If the patient met the morning star, suffer from pain in the fingers, then the tattoo it must be operated.”
Medical treatment and treatment of certain forms of felons
Paronychia. Practitioners often underestimate this pathology, considering it serious. Meanwhile, if the wrong treatment paronychia may take a chronic course, delivering a lot of trouble the patient.
The cause paronychia usually is burrs or disease develops after an injury skin roller in manicure. There is swelling, redness paranail roll, intense pain. Further there is detachment of the epidermis roller manure on the edge nail plate begins to develop abnormal granulation. Treatment should begin as soon as possible. At the first signs of inflammation (redness, pain) should strike a thin gauze or ribbed strip soaked alcoholic chlorhexidine solution under the skin paranail roll, bundle it from the nail plate in the area of inflammation. In some cases this is enough to reduce inflammation within 2-3 days. When a detachment of the epidermis manure should immediately neatly cut (ie cut, not just pierce – as is often erroneously) peeling area to evacuate purulent exudate and apply a bandage with an alcoholic solution of chlorhexidine, caused by skin roller gauze strip soaked with this solution. In case of skin between paranail ridge and nail plate pathological purulent granulation – required surgical treatment. A cut on the dorsum of the nail phalanx, carefully remove all necrotic tissue, granulation, sometimes have resect a sprout area nail plate. Postoperatively, the wound is open, Bandages with ointment “Levomekol.”
Skin whitlow. Developed as a result of microtrauma. Often skin felon accompanied by severe symptoms of lymphangitis and lymphadenitis, which may disturb the patient more than the original process.
Surgical treatment – carried removal of exfoliation of the epidermis, usually does not require anesthesia. Evacuated purulent exudate, then you must carefully examine the eroded surface, so as not to miss a felon as a “cuff” (when suppurative process spreads narrow course in the subcutaneous tissue). Inflammatory effects disappear within 5 – 10 days depending on the prevalence of the process.
Subungual whitlow. The disease occurs as a consequence of paronychia, with direct introduction of infection under the nail plate (needle stick, nail), or a complication of subungual hematoma (often after trauma finger door). Prevention of disease – competent treatment paronychia and early evacuation of subungual hematoma after injury. When delimited local detachment nail plate manure (less than 1/3 of its total area) is allowed to perform resectioail only the distorted area. In case of more extensive damage to completely remove the nail plate, nail retaining sprout area (if possible). Typically erosion surface nail bed well epithelizing on average 10 – 15 days after surgery.
Subcutaneous whitlow. The disease develops in contact infection in subcutaneous finger with the further development of purulent inflammation. Typically a consequence of microtrauma – injection, cuts, splinters, etc. First appears mild swelling and redness finger further inflammation progresses, the pain become pulsating nature, are very intensive. On the nail phalanx finger held oblique incision on the middle phalanx and the main incision is made on the lateral surface. Skin and subcutaneous flaps are raised in different directions and performed a thorough necrectomy. Typical error in treating subcutaneous felons – failure necrectomy. Very often, surgeons are limited to only cut on inflammation, which leads to temporary improvement being patient, and suppurative destructive process spreads to deeper tendons and bone foundation finger. After necrectomy cavity formed, executed gauze strip of Levomekol so that the edges of the wound were divorced. Further, performed daily replacement of bandages. When adequately executed necrectomy in the postoperative period in the wound should not be a purulent discharge. The presence of pus within 2-3 days after the operation is an indication for repeated necrectomy. After cleaning the cavity in the subcutaneous tissue wound edges adapted plaster can impose secondary sutures.
Tendon whitlow. One of the most difficult types of felons. There is a symptom of purulent abscess. The disease develops or because the primary introduction of infection into the flexor tendon sheath (for cuts, puncture, etc.), or progression of subcutaneous process with inadequate treatment of the latter. With the development of septic infection in tendon sheath clinical picture is quite bright – patient concerns expressed pain along the tendon, any movement is extremely painful. Surgical assistance should be provided as early as possible because the tendon quickly die under ambient purulent process. The operation is performed under regional anesthesia.
In the absence of purulent inflammation in the subcutaneous fat finger (and it happens when the infection enters directly into the shell of the tendon at the prick) is allowed to perform surgical treatment of primary wounds, tendon vagina revealing in this area, and make the cut in the projection of “blind twisting” flexor tendon sheath also dissection of the latter. Vagina thoroughly washed antiseptics on both sides and drains perforated polymer tube.
Where there is a purulent inflammation of subcutaneous tissue incision is made on the lateral surface of the finger with the palm arched extension in the projection of “blind twisting” flexor tendon sheath. Palmar skin and subcutaneous flap preparation from surrounding tissues, provide a thorough necrectomy in fat, menus and sanation of tendon vagina. In identifying necrosis tendon last resection within healthy tissue. The operation completes execution wound gauze strip of Levomekol so that the edges of the wound were maximally deployed, allowing for further dressings monitor the tendons (if saved). Later, as cleaning the wound, the edges adapted strips or superimposed secondary sutures. With confidence in the completeness of implementatioecrectomy possible stitching of wound after the imposition of drainage drilling system (system of perforated plastic pipes, drainage cavity formed).
Articular whitlow. Developed in direct contact infection in the joint space (when injured), or as a consequence of prolonged purulent process in the soft tissues of the finger joint. Often surgeons with arrangements festering wounds in the projection knuckles not revise the joint capsule and damage the latter are visible, and suppurative arthritis diagnosed later, when there is a characteristic clinical picture. For articular panaritiums typical fusiform enlargement finger in projection interphalangeal joint, marked limitation of motion in the joint, pain on palpation and during movement, abnormal mobility and crepitus in the joint.
Treatment is only surgical – performed arthrotomy, thorough dental antiseptics joint, then the joint cavity drains perforated polymer tube. It is necessary to be sure to close the wound on the cavity of the joint. The fundamental point – after surgery should be distraction to reduce intra articular pressure and prevent further destruction of the articular ends. Distraction is made or overlapping distraction device, or removing the finger from the nail phalanx, gips spokes Kirchner. Distraction spokes Kirchner terminated with decreasing inflammation (7-10 days), and distraction device is held in the fingers 1-1,5 months., It begins to develop movement in the joint.
Bone whitlow. Develops, usually either by direct contact infection in bone (with infected open fractures), or dissemination of purulent process on the bone with surrounding soft tissue at the wrong treatment of more superficial suppurative processes in the fingers. Very quickly the infection spreads to comb nail phalanx in the development of purulent process on top of a finger. If this zone purulent inflammation persists for 6-7 days, we can assume that the bone is involved in the process, even in the absence of radiographic changes. Generally, it must be remembered that the X-ray picture always sometimes “late” compared to real changes in the tissues. Despite this, the x-ray examination – a mandatory component in the diagnosis of bone felons. Treatment is surgical. A section that provides good exposure for the revision of the affected bone. After necrectomy in the soft tissues is performed sequestrectomy in bone from the finger bone sharp spoon – gently dissection of affected areas. All viable piece of bone stored. If surgery is performed under conditions of acute inflammation in the soft tissues of the finger, the operating wound is opened (ligation of Levomekol). In the case of an operation when remitting inflammatory phenomena (for long periods of the disease, fistula formation) after radical necrsequestrectomy possible closure of the wound with leaving perforated plastic drainage of trapped finger formed. Rolls daily for dressings and washed away for 5-7 days.
Osteoarticular whitlow. Develops, usually due to the progression of articular felons, with inadequate treatment of the latter. When the disease occurs in suppurative process involving the articular ends of the interphalangeal joints with the development of their destruction. The fundamental difference from pandactylitis is to keep tendons surrounding the joint (flexors and extensors). Treatment is surgical. Often made oblique cut on the rear toe in the projection corresponding joint or incision on the side of the finger (when you cannot completely eliminate the proliferation of purulent process on the palmar surface of the finger).
Exposed extensor tendons, which can detect a defect that leads into the joint cavity. Tendons cut over joints in the longitudinal direction of the fibers apart, which provides a good overview of the joint cavity. A removal of purulent exudate, purulent pathological granulation of the joint cavity, washing antiseptics. Then a sharp spoon gently carried sequestrectomy in the affected bone sites. After the final dental replacement last drained in the transverse direction perforated polymer tube, the ends of which are derived through separate beats. Restored the integrity of the extensor tendons atraumatic thread 6/0 and superimposed skin sutures. With extensive resection of the articular ends when between them created diastase than 4 mm special decompression is required. If the pressure is kept articular ends of each other, the required decompression in the joint by applying distraction device, or by extraction from nail phalanx (see articular felon)
Pandactylitis. This is the hardest purulent affection of thumb. Includes skin lesions, subcutaneous tissue, tendon structures, bone and (or) joint. So far, many sources you can find recommendations to amputate the finger at pandactylitis. However, at the present stage of development of medicine should seek to preserve the anatomical integrity of the finger and its functional activity.
Surgical access for this pathology should provide a good overview of all of the affected structures. The incision is made on the lateral surface of the finger. If necessary revisions zone “blind” twisting flexor tendon sheath incision along the arc continues on hand in the projection head corresponding metacarpal bone. Blunt stands palmar neurovascular bundle finger, then palmar skin and subcutaneous flap peels of flexor tendons. Similarly preparated rear flap. Both patches are deployed, providing good exposure. Performing thorough necrectomy in all structures finger, according to those principles, which are described in the treatment of subcutaneous, tendon, joint and bone and articular felons. If necessary, superimposed drainage flushing system, according to the postoperative period is distraction in a joint way or another method. In some cases, resulting necrectomy or from primary trauma formed extensive skin defects. Their earliest, as cleaning wounds should be closed cutaneous grafting to avoid degradation of subordinate structures. In the presence of granulation in the wound, preference should be given free plastic split skin graft, if the wound bare tendon and bone structures – expedient plastic (one way or another). This approach allows in many cases to avoid undue amputation of a finger.
Phlegmons of brush
Classification. Highlight localization following phlegmons:
1. Interdigital phlegmon
2. Phlegmon thenar region
3. Phlegmon hypothenar region
4. Epyaponeurotic medial palmar space abscess
5. Subaponeurotic medial palmar space abscess:
a) surface,
b) deep,
5. Phlegmon rear brush
6. Cross (U-shaped) abscess brush with defeat space Pirogov-Paronymy
7. Associated phlegmons.
This diffuse purulent lesions fat spaces brush. Depending on the location have characteristic symptoms. Local signs of inflammation include swelling and redness tissue dysfunction hand, the local temperature increase tenderness. The degree of severity of these symptoms varies and depends on the extensiveness of the inflammatory process, the virulence of the pathogen defense response, its immunobiological reactivity, etc.
A sharp increase of the thumb accompanied by swelling of the thenar and sharp radial edge of the back surface of the brush. Sharp pain on palpation, tissue tension, limiting the mobility of the swollen tissue thenar, palmar smoothing skin folds – the characteristic symptoms of inflammation of the fat tenor.
A sharp hypothenar revealed moderate edema, hyperemia and tissue tension, tenderness on palpation. Movement five fingers lead to increased pain.
Commissural abscess. Atrium is cracked corn rough skin in the metacarpophalangeal joints palm. Hence another name – corn abscesses, “Namin.” Inflammatory foci formed, usually in commissural spaces P-V fingers.
A sharp accompanied by pronounced pain, swelling of the distal surfaces of both hands. Fingers in the neighborhood of septic foci slightly separated and bent at the interphalangeal joints. Extension of painful because of tension inflamed palmar aponeurosis. Perhaps direct distribution of manure through oval slit of palmar aponeurosis on the dorsum of the hand, and the involvement of deep flexor tendon, which is in close proximity to the purulent focus. Spreading infection can occur in the proximal direction through the channels vermiform muscles. In these cases, the main foci of inflammation joins medial palmar space.
Phlegmon medial palmar space between localized palmar aponeurosis and fascia covering the flexor tendons of the fingers – subaponeurotic abscess. Clinically, accompanied by severe purulent intoxication, headaches, high fever. The central part of the palm exploding palmar creases smoothed, fingers bent and attempt active or passive movements in them accompanied by a sharp pain.
Overlapping or U – shaped abscess. It is the result of combined lesions of synovial bags palm – ulnar and radial. The disease is the result of festering abscess 1 or V finger. Under certain conditions, manure spreading on synovial bag or radial ulnar side of the hand, causing inflammation. These phlegmon involving severe intoxication, high fever, general weakness, headache. Brush swollen, blue, fingers bent movements in them because of pain possible. Palpable biggest pain in the area of the projection of the flexor tendons 1 and V finger in the proximal part of the hand.
Subcutaneous abscess Dorsum of the hand causing swelling and hyperemia without clear boundaries subcutaneous tissue and skin on the rear hand. Accompanied by pain, fever, lesions of the hand and fingers.
Subaponeurotic phlegmon Dorsum of the hand are tight, painful infiltrate, edema and hyperemia of the skin on the rear hand. These cellulitis, is usually secondary to inflammatory diseases of the palmar surface of the hand. Boil, carbuncle brush. Local manifestations typical for all locations boils and carbuncles. Functional activity of the brush is always broken. Sure abscess developed secondary brush. Inflammatory foci formed, usually in commissural spaces II – IV fingers. Openings palmar aponeurosis contribute to the spread of infection from superficial abscesses inside.
General principles of treatment phlegmons:
• Treatment of patients with phlegmon of the hand should be in the surgical hospital.
• It is necessary to accurately determine which fat space brush amazed that it is important to select adequate access.
• Surgical intervention should be early and be in strict compliance with the rules of asepsis.
• Necessary optimal analgesia and complete bleeding hand.
• necrectomy and drainage of abscess – the most important moments of operation.
• Adequate antibiotic therapy based on sensitivity microflora.
• The use of different types of local therapy after surgery, depending on the location of inflammation.
• Immobilization.
• Rehabilitation of patients, prevention of complications.
Errors in the treatment of felons and phlegmons
The most typical mistake outpatient surgery is rejection of primary surgical treatment of accidental injuries brush. Purulent wound must be subjected to surgical treatment – under regional anesthesia performed necrectomy with the audit of all damaged structures. Special attentioeeds to wounds on the dorsum of the fingers and hands in the projection interphalangeal and metacarpophalangeal joints.
Errors of diagnosis. To establish the correct diagnosis at the clinic does not require expensive equipment or performing complex analyzes. It is enough to collect history, carefully examine the patient and perform hand radiographs. Wrong diagnosis forms felons or phlegmons entails inadequate surgical care and ultimately can lead to disease progression. We consider it necessary to identify a number of important aspects that will help make the correct diagnosis.
Purulent inflammation of the palm and dorsum of the fingers and hands proceeds differently due to different structure of subcutaneous tissue. At the rear brush spread purulent exudate occurs mainly on the plane while on the palmar surface of the zone of necrosis rapidly distributed in the tissues, involving destructive process tendon and bone structure. The structure of the fiber palmar surface of the type of “hundreds” makes futile attempts of conservative treatment of purulent wounds of localization without adequate necrectomy, while the rear hand conservative measures in some cases can be justified.
Prolonged purulent discharge from the wound distal phalanx of the finger nail (for five or more days) to consider the possibility of bone felons with lesions comb nail phalanx, even with a negative X-ray picture. In this zone, the process quickly spread to the bone, and changes on radiographs are usually late and found the 10-14th day of the disease.
With the localization of wounds and inflammation on the fingers in the projection of the flexor tendon sheaths, be sure to check for tenderness to palpation probe bellied in the projection of “blind twisting ‘tendon sheaths even at constant integuments in this area. Severe pain along the flexor tendons due to accumulation of inflammatory exudate, allows the development of tendon suspected felons, but in this pathology operational assistance should be made as early as possible to avoid the development of necrosis tendons.
Abnormal lateral mobility and crepitation in the interphalangeal joints, especially in the localization of the wounds in the projection of joint allows great confidence diagnose articular or osteo-articular felons.
Wounds in the projection metacarpophalangeal joints require a thorough revision, as often penetrate into the joint cavity that remains unrecognized by the review. Later, when developing destructive foci in bone structures that articulate the function of the joint and the finger will be irreversibly lost.
Errors when performing anesthesia. One of the mistakes that often occur is inadequate anesthesia. Patients with long remember feeling pain during surgery and continue with fear waiting for repeat their sensations in some cases as an excuse to abandon the operation.
In addition, the method of anesthesia is not always selected correctly. In inflammatory diseases of the fingers and hands local infiltration anesthesia should not be used if you do not provide adequate relief. Displaying perform anesthesia at different levels (level metacarpal bones, wrist, upper third of the forearm, axillary fossa), and the injection of anesthetic should be located outside the inflammation. We believe strongly contraindicated multiple input local anesthesia solutions of antibiotics in inflamed edematous tissue because this procedure leads to a further increase of interstitial pressure with subsequent necrosis of soft tissues.
Errors in choosing operational access. Illegal repeated parallel sections of the palmar surface of one phalanges. This skin “bridges” necrotising, sections do not provide adequate outflow of fluid, and most importantly, these wounds further complicating the implementation of radical necrosectomy.
Access during surgery for inflammatory diseases of fingers and hands should be chosen depending on the presence or absence of wounds. With existing skin lesions on the back or volar surface blemishes to economically cut and cut to simulate the type Z-like fingers and arched or S-shaped at hand. At wounds on the sides of the finger section expands on the “neutral line”. When intact integument access the fingers should be on the side surfaces or Z-shaped with the back surface. Palmar surface of the finger should be possible to spare. Categorically unacceptable conduct long longitudinal incisions in the palm and dorsum of both fingers and hands, as it further leads to marked scar contractures and severe disorders of sensitivity.
Errors in the processing of purulent focus. Rough and unfortunately, the most common error that occurs is to perform skin incision without removing necrotic tissue hoping to further self-exclusioecrosis by ligation. This tactic is flawed because after opening pressure in the tissues is reduced, decreasing pain, doctor and patient is regarded as a positive trend, but this time suppurative destructive process progresses into the tissue, affecting important anatomical education. Further radical necrectomy can result in amputation or phalanx.
Necrectomy – a prerequisite surgery panaritiums and phlegmon brush. Any removal of nonviable tissue on the fingers and hands should be performed with full bleeding, which is achieved by imposing the rubber bands on your finger or on the tonometer cuff on the forearm. Suppose also use rubber bandage on the forearm, which is superimposed on the spiral. Manipulation of tissues “blind” can cause damage to the neurovascular bundle and tendon structures with all its negative consequences.
Errors in the completion of surgery and postoperative care. Necrectomy fingers and hand finished dental antiseptic solutions and loose performance wounds with gauze strips or napkins with ointments on water-soluble basis (levosyn, Levomekol etc.). Use liniment Vishnevsky and ichtiol ointment at present is unacceptable because these tools facilitate the progression of suppurative destructive process. In the absence of signs of deterioration in the local process strip away from the wound on the second or third day. Visually estimated state cavity. If adequate necrectomy wall cavity in these terms are clean, there is granulation, discharge from the wound meager, sero-purulent. If the wound with copious purulent discharge from necrotic tissue, perifocal inflammation with no tendency to reduce the need to decide on re necrectomy.
