Panaricium

Panaritium (Latin: panaritium) is an acute, purulent inflammation of the finger. It consists of some local purulent processes that have independent etiopathogenesis (infected fractures and dislocations, foreign bodies, burns, etc.).

Unlike domestic literature, in English literature purulent inflammation of the subcutaneous tissue of the nail phalanx of the finger is designated "felon", and the rest of the phalanges - "cellulitis". Phlegmon of the hand (Greek phlegmone) is a purulent inflammation of the tissue that develops directly on the hand or as a result of the spread of the purulent process from the finger.

The peculiarity of the pathology is determined by the anatomical structure of the fingers. Connective tissue bridges pass from the skin to the phalanges of the fingers, which limit the purulent process when it occurs; but at the same time they are conductors for deepening the inflammation. The main cause of the development of panaritiums is microtrauma.

Panaritium is a common pathology and accounts for up to 30% of outpatient visits. The incidence is higher in men who work with irritants and the possibility of mechanical damage to the fingers. But purulent wounds of the fingers do not belong to the category of panaritiums.

Epidemiology

Panaritium is the most common purulent process. Of all primary patients who seek surgical attention, patients with panaritium and phlegmon of the hand make up 15 to 31%. Moreover, in recent years, there has been a tendency for this pathology to grow. The suppurative process complicates over 40% of minor injuries to the hand, which makes microtrauma one of the leading factors in the development of severe purulent processes on the fingers and hand.

Economic losses associated with temporary disability due to purulent diseases of this localization are many times greater than those due to inflammatory processes of other localizations, since they more often occur in men of working age (from 20 to 50 years) and affect mainly the right hand.

Difficulties in treating panaritium are associated with late appeal of patients for medical care, decreased effectiveness of antibacterial therapy, unreasonably long conservative treatment, incorrect or insufficiently radical primary surgical intervention, which predetermines the growth of the number of patients with advanced and complicated forms of the disease. In almost 60% of cases, the cause of complications is considered to be the non-radical nature of surgical interventions performed in outpatient clinics. Repeated operations in 25% of cases end in injury of the fingers and hand, leading to disability in 8.0% of patients. The highest percentage of unsatisfactory results was noted in the treatment of bone, tendon, articular, osteoarticular panaritium and pandactylitis, as well as combined and combined phlegmon of the hand. In 17-60% of patients with bone panaritium, amputations of the phalanges are performed. Unsatisfactory results of pandactylitis treatment also reach 60%.

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What causes felon?

In recent years, under the powerful selective effect of antibacterial drugs, significant changes have occurred in the structure of pathogens that cause panaritis. Staphylococci and gram-negative bacteria belonging to the Enterobacteriaceae family or to a large group of so-called non-fermenting gram-negative bacteria have come to the fore. Staphylococcus aureus dominates in 69-90% of cases, less often in monoculture, more often in associations, and its sensitivity to penicillins is noted in no more than 10% of cases. A significant role is also played by obligate non-spore-forming anaerobic bacteria and opportunistic microflora. Beta-hemolytic streptococcus is rarely isolated. The frequency of mixed gram-positive and gram-negative microflora, as well as aerobic-anaerobic associations, has increased.

In some patients, the infectious process on the hand progresses into a severe pathology - anaerobic non-clostridial phlegmon of the upper limb. Of the variety of non-clostridial anaerobes, the following clinically important groups should be distinguished: anaerobic non-spore-forming gram-negative rods (Bacteroides and Fusobacterium), anaerobic gram-positive cocci (Peptococcus and Peptostreptococcus) and gram-positive non-spore-forming rods (Actinomyces, Propionibacterium, Eubacterium).

Panaritium in the vast majority of cases is the result of trauma. Violation of the integrity of the skin, even as a result of microtrauma, is a necessary prerequisite for the development of this pathology. One of the reasons for the development of phlegmon of the hand with a severe course of the inflammatory process should be considered wounds from bites or bruises from teeth. Anaerobic and putrefactive infection are especially characteristic of them.

Symptoms

The leading symptom of any panaritium is pain. The intensity of pain varies from aching to unbearable; it can be pulsating, intensify at night and deprive patients of sleep. Because of the pain, patients almost always hold the sore hand in an elevated position. It is typical that with a spontaneous breakthrough of pus to the outside, the pain syndrome significantly subsides, which creates a false impression in patients about the improvement of the finger condition. Almost simultaneously, swelling of the soft tissues increases, the severity of which can vary from the involvement of only the periungual fold in paronychia to a sharp thickening of the entire finger in tendovaginitis or pandactylitis.

Hyperemia is a fairly common symptom of panaritium, but it may be expressed insignificantly or even absent in deep forms of the disease. At the same time, local hyperthermia of the skin of the affected finger is present almost constantly. As the disease develops, a violation of the finger's functions becomes obvious, especially limitation of movement in it. This is most clearly manifested in deep forms of panaritium with the involvement of joints or tendons in the purulent process. The development of panaritium is often accompanied by a deterioration in the general condition of patients, an increase in body temperature, weakness, and malaise. These phenomena are especially pronounced in lymphogenic complications of the local inflammatory process.

Cutaneous panaritium is an accumulation of pus between the epidermis and the skin itself and manifests itself as a characteristic syndrome in the form of a “bubble” with accumulated purulent exudate, often complicated by lymphangitis.

Paronychia is an inflammation of the nail fold. It often occurs after a manicure or hangnail removal. Edema, hyperemia of the skin and pain in the area of the nail fold are typical. Despite the apparent simplicity of treatment of this pathology, in some cases the disease can become chronic. There is an overgrowth of granulations in the area of the base or edge of the nail plate (the so-called wild meat) with prolonged serous-purulent exudation, which can subsequently lead to the development of bone destruction of the nail phalanx.

With subungual panaritium, purulent exudate accumulates under the nail plate. As a rule, it occurs as a result of the progression of the purulent process in paronychia or after an injection under the free edge of the nail.

Subcutaneous felon is a purulent-destructive inflammation in the subcutaneous tissue. It develops after micro- or macrotrauma of the skin of the finger. At the same time, on the palmar surface of the finger, due to the structure of the subcutaneous tissue according to the "honeycomb" type, the intra-tissue pressure quickly increases and necrosis occurs even without free purulent exudate.

A synonym for tendon panaritium is purulent tendovaginitis. A characteristic symptom complex caused by the accumulation of purulent exudate in the narrow space of the tendon sheath occurs with primary microtrauma of the flexor tendon sheath or as a complication of subcutaneous panaritium. Pinpoint palpation of the finger tissues with a button probe helps to establish an accurate diagnosis, which reveals maximum pain along the affected tendon.

The development of destructive changes in the bone base of the finger is the basis of bone panaritium. It occurs as a complication of another form of panaritium or after extensive trauma with bone damage. The clinical picture varies from flask-shaped tissue edema with fluctuation, hyperemia and pain in acute inflammation to virtually painless phalanx damage with a purulent fistula. The difficulty is that radiographic signs of bone destruction are "late" from real changes in bone tissue by 7-12 days, which is a common cause of late diagnosis.

Articular panaritium occurs as a result of the progression of subcutaneous and tendinous panaritium or after an injury with primary damage to the interphalangeal joint. The clinical picture is dominated by signs of acute inflammation with characteristic edema in the area of the affected joint, pain and hyperemia. Movements in the joint and axial load on it are sharply painful. The radiograph often reveals a characteristic narrowing of the joint space.

Osteoarticular panaritium, as a rule, is a consequence of articular panaritium if the latter is treated incorrectly. In the diagnosis of the disease, one of the important clinical signs is the appearance of pathological lateral mobility and crepitus in the joint. The presence of characteristic signs on the radiograph (narrowing of the joint space in combination with foci of destruction in the articulating articular ends) is also important.

Pandactylitis is the most severe purulent pathology of the finger. It is characterized by damage to all anatomical structures of the finger (skin, tissue, tendons, bones and joints). It occurs either as a result of progression of panaritium, or after extensive trauma to the finger with damage to all anatomical structures. The fundamental difference from osteoarticular panaritium is extended destructive changes in at least one of the tendons, requiring partial or complete resection of the latter. Often, with pandactylitis, it is impossible to save the finger, so amputation of the phalanges or the finger as a whole is performed.

Classification of panaritium

Depending on the location of the abscess, panaritium is divided into superficial and deep. Deep panaritium, as a rule, is a complication of superficial ones if they are treated incorrectly, the microflora is highly virulent, there is concomitant pathology that aggravates the course of purulent processes (diabetes mellitus, vitamin deficiency, immunodeficiency, oncological diseases) and reduces the body's resistance.

Superficial panaritiums

Common manifestations for all forms of superficial panaritiums are: pain in the finger of a bursting or twitching nature; swelling and hyperemia with blurred edges, spreading to the entire finger, but most pronounced in the area of the abscess; painful contracture of the finger, disrupting the function of the entire hand. Against this background, signs characteristic of each type of panaritium are determined, allowing its form to be differentiated.

1. Cutaneous felon. Against the background of edema and hyperemia of the finger, intradermal blisters (one or more) filled with pus are formed. When performing surgery, one must be wary of a "cuff-shaped" felon, when there is a deep abscess that has opened into the skin as a fistula.
2. Subcutaneous whitlow. The localization of the abscess in the subcutaneous tissue. The nail phalanges are predominantly affected. Edema and hyperemia are widespread, but a whitish area often forms over the abscess area. The localization of the abscess is determined by a probe ("the finger cannot be palpated by a finger!") based on maximum pain.
3. Periungual felon (paronychia). Most often occurs after a manicure, tearing off skin hangnails. The abscess is localized in the periungual fold or on the lateral surface of the nail. The microflora can be typically purulent or fungal, which is more common.
4. Subungual felon. Most often develops with existing paronychia, when pus penetrates from the periungual fold under the nail. Diagnosis is not difficult, since the pus is visible under the nail.

Deep felons

They develop initially very rarely and in most cases are a complication or outcome of superficial panaritiums.

1. Tendinous felon. Purulent inflammation of the tendon itself is very rare. More often it is its transitional, reactive inflammation, of the exudative type, with pronounced edema and infringement in the tendon sheath. Hence the urgency of providing assistance, since the tendon can become necrotic. The patient must be sent to the hospital by ambulance for emergency assistance. The clinical picture is pronounced: the finger is placed half-bent; attempts to straighten it cause sharp pain; palpation of the tendon in the Pirogov space and the belly of the muscle is sharply painful.
2. Articular felon. Morphologically defined as destructive arthritis with necrosis of the articular surfaces, which must be confirmed by X-ray. The interphalangeal joint swells, a bluish hyperemia appears above it, the finger takes on a "spindle-shaped" form.
3. Bone felon. Most often, the nail phalanx of the first finger is affected. It acquires a "club-shaped" form. X-rays reveal bone destruction in the form of an osteomyelitic process.
4. Pandactylitis is a purulent inflammation of all tissues of the finger.

Complications of panaritiums

1. Spread of purulent process to distal sections with development of abscesses or phlegmons of the hand and Pirogov space. They proceed with typical clinical picture. Localization of abscesses is epi- or subfascial, on the back or palmar surface of the hand.

2. Involvement of the lymphatic vessels (lymphangitis) and lymph nodes (lymphadenitis) in the process is one of the indicators of inadequate local treatment.

3. Involvement of venous vessels in the process with the development of thrombophlebitis and periphlebitis is rare, but requires hospitalization.

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How to recognize a felon?

Diagnosis of panaritium for a practicing physician based on a combination of anamnestic and clinical signs usually does not present any difficulties. It is much more difficult and extremely important to establish the type of panaritium at the preoperative stage, which largely determines the surgical tactics. In this regard, the following diagnostic algorithm is justified when examining each clinical case:

• careful collection of anamnesis (nature and duration of primary injury or microtrauma, treatment administered, presence of concomitant pathology);
• assessment of the results of an objective examination (type of the affected finger, changes in the skin, localization and severity of pain during pinpoint palpation with a button probe, presence of pathological mobility in the joint or bone crepitus, etc.);
• analysis of radiographic data of the affected finger.

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Differential diagnostics

Given the high activity and contact of the hand, boils, carbuncles, and anthrax carbuncles can form on the fingers, which do not present any difficulties in differential diagnostics. More often, panaritium has to be differentiated from erysipiloid ("pig's erysipelas"), caused by a specific bacillus. They become infected when cutting raw meat (usually pork) or fish.

A distinctive feature is cyanotic hyperemia with clearly defined boundaries.

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How to prevent felon?

Reducing industrial and domestic injuries is considered the most effective method of preventing panaritium. Complete sanitation of minor skin injuries, timely primary surgical treatment of wounds can reduce the risk of developing purulent complications to a minimum.

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What is the prognosis for felon?

Timely and complete treatment of panaritium allows us to state a favorable prognosis for the life of patients.