Treatment of phlegmon of the hand

The diagnosis of "phlegmon of the hand" is an absolute indication for emergency or urgent surgical treatment. The task of preserving the function of the hand should be set before the surgeon from the very beginning. Even before making an incision on the hand, one should think about the area and the type of scar, to what extent it will affect the function of the hand. Incisions are made taking into account Langer's lines, corresponding to natural skin folds. It should be especially noted that making large longitudinal incisions is unacceptable. Surgical approaches should be as short and gentle as possible. Creating a wide access is possible by modifying the incision as S-shaped, arcuate or broken, remembering that the scar contracts the tissues along the length. Incisions "through all layers" are unacceptable for opening a purulent focus. Only the skin is cut with a scalpel. All further manipulations on tissues are performed using clamps and hooks, which allows visualization and preservation of all functionally important structures (vessels, nerves, tendons). The presence of an assistant during hand surgery is mandatory.

The next stage of the operation is a thorough necrectomy, in which the purulent focus should be excised according to the type of primary surgical treatment. During necrectomy, the vessels and nerves are actually skeletonized. The affected tendon should not be resected if it is possible to limit the removal to individual necrotic fibers. Necrectomy on bone and joint structures should include the removal of only sequestered areas. Interventions on joints in purulent arthritis or osteoarthritis should be carried out in the postoperative period in the distraction mode, which is most often ensured by traction with a modified Kirschner wire or with a special device.

After necrectomy and hemostasis, each cellular space is drained with a separate perforated polyvinyl chloride tube, which is fixed to the skin with a separate suture. After interventions on joints and tendon sheaths, these structures require additional drainage. Wounds are treated with an antiseptic, vacuumed and treated with low-frequency ultrasound in an antibiotic solution.

Performing radical necrectomy and adequate drainage of the residual purulent cavity allows completing the operation by applying primary sutures to the wound. Wound suturing is performed with atraumatic threads 3/0-5/0. In case of severe damage to the hand, the use of microirrigators and partial wound suturing is supplemented by applying gauze dressings soaked in ointment on a hydrophilic basis.

If it is impossible to immediately suture a skin defect, it is necessary to use various types of skin grafting more widely. In cases of exposed tendon or bone, it is possible to use non-free skin grafting of the Italian type, crossed from finger to finger, or a flap on a vascular-nerve pedicle. Granulating defects are preferably closed with a free split skin graft. All plastic surgeries are performed after the relief of acute purulent inflammation, but as early as possible.

An important point after hand surgery is correct immobilization with observance of measures to prevent skin maceration. The immobilization period of a hand operated on for a purulent process should be limited by stopping acute inflammatory phenomena.

In the postoperative period, along with regular wound sanitation, antibacterial and anti-inflammatory therapy, physiotherapy procedures, and exercise therapy are performed on dressings. Early active development of finger and hand movements (after removal of drains and sutures) contributes to a more complete restoration of hand function.

Treatment of phlegmon in the interdigital space

If one interdigital space is affected by a purulent process on the palmar surface of the hand, an arcuate Bunnell incision is made at the level of the heads of the metacarpal bones. A counter-opening incision is made on the back of the hand in the projection of the corresponding space. The wounds are connected to each other and drained with a through-and-through perforated microirrigator with the application of primary sutures. If two or three interdigital spaces are affected, one arcuate skin incision is made on the palmar side of the hand parallel to the distal transverse fold. Separate incisions are made on the back of the hand, as in the case of a lesion of one interdigital space, but in a quantity corresponding to the number of spaces involved in the purulent process. All dorsal wounds are connected to the incision on the palmar surface. A microirrigator is passed through each interdigital space, and another tube is placed on the bottom of the palmar wound in the transverse direction.

Treatment of phlegmon of the thenar region

Surgical access is an arcuate incision up to 4 cm long, made parallel to the thenar skin fold and slightly outward from it. Care should be taken when performing the proximal part of the incision, in the so-called "forbidden zone", where the motor branch of the median nerve passes to the muscles of the thumb. Damage to it leads to immobilization of the finger. A contra-opening arcuate incision is made on the back of the hand in zone 1 of the interdigital space. After performing necrectomy and wound sanitation, the cavity is drained with two perforated tubes, one of which is carried out along the inner edge of the thenar area, and the second - along the main incision on the palmar side of the hand. Treatment of phlegmon of the hypothenar area. A linear-arc-shaped incision is carried out along the inner edge of the hypothenar muscle eminence. The dorsal contra-opening incision corresponds to the outer edge of the 5th metacarpal bone. Having completed the main manipulations in the purulent focus, the wounds are connected to each other. Drainage is carried out with two tubes, one of which is passed along the inner edge of the fascial bed of the hypothenar, and the second along the main incision.

Treatment of phlegmon in the supra-aponeurotic region

The following approaches are optimal:

• Bunnell arcuate incision, carried out from the 2nd interdigital space of the palm at the level of the distal transverse fold parallel and medial to the thenar fold to the distal border of the wrist joint (it is possible to use a fragment of this approach);
• arcuate incisions parallel to the distal or proximal transverse palmar grooves (according to Zoltan).

Confirmation of the supra-aponeurotic localization of the lesion makes it unnecessary to dissect the palmar aponeurosis with the introduction of through drainages through counter-aperture incisions on the back of the hand. The stage of necrectomy and sanitation of the lesion is carried out in a standard manner using proven methods, after which two perforated microirrigators are installed in a Y- or T-shape.

Treatment of phlegmon of the medial palmar space

For opening of phlegmons of the median palmar space, the method of choice should be considered the modified Zoltan approach. The incision begins from the IV interdigital space parallel to the distal transverse skin fold to the II interdigital space, then continues to the proximal transverse fold, from which it is also directed in an arcuate manner in the proximal direction along the thenar fold to the "forbidden zone". Mobilization of the formed flap together with the cellular tissue (to maintain its blood supply) provides access to almost all cellular spaces of the palmar surface of the hand, which creates conditions for performing a complete and wide necrectomy.

If there is a wound of significant size in the area of the base of the planned incision (after primary trauma or operations in other medical institutions), the risk of ischemia and subsequent necrosis of the flap increases significantly. In these cases, it is advisable to perform an incision similar to that described above, but as if mirrored relative to the longitudinal axis of the hand.

In case of significant damage to the skin in the central part of the palm, it is undesirable to perform any of these incisions. In these cases, it is advisable to perform an arcuate median incision along the axial line of the hand, starting from the second interdigital space and ending with the proximal edge of the projection of the flexor retinaculum.

Regardless of the chosen approach, the dissection of the palmar aponeurosis is performed in the longitudinal direction and necrectomy is performed as it moves deeper into the tissue. Revision of the flexor tendons themselves and the subtendinous (deep) space is necessary to assess their condition and identify possible purulent leaks.

After necrectomy, drainage is performed. Usually, three or four microirrigators are sufficient: two or three tubes (depending on the extent of the process) are placed under the palmar aponeurosis, then under the transverse ligament of the palm and brought out through additional punctures at the level of the distal fold of the wrist area and in two or three (according to the number of drains) interdigital spaces. Another microirrigator is placed under the flexor tendons in the transverse direction and brought out through additional punctures. After installing the drains, the integrity of the palmar aponeurosis is restored (atraumatic suture material 3/0-4/0).

Contrary to the frequently mentioned technique of performing counter-opening incisions on the back of the hand and through palmar-dorsal drainage for this pathology, if there is confidence in the absence of leaks on the back of the hand (through the intermetacarpal spaces), there is no reason to complete the operation in this way.

Treatment of phlegmon of the back of the hand

The opening of the phlegmon of the back of the hand is carried out by several small arcuate (up to 3.0 cm) incisions along the Langer lines along the perimeter of the purulent cavity. The entrance gates are subject to surgical treatment and can be used as one of the approaches.

To drain the resulting cavity, two microirrigators are placed longitudinally along its lateral and medial edges, brought out through additional punctures. It should be emphasized that primary sutures are indicated only if there is complete confidence in the viability of the tissues of the back of the hand. In case of skin defects after necrectomy or obvious ischemia of the skin of the back of the hand, it is preferable to loosely fill the wounds with gauze strips with a water-soluble ointment.

Treatment of phlegmon of the hand and Pirogov-Parona space

Surgical intervention for U-shaped phlegmon begins with unilateral longitudinal lateral incisions along the "non-working" surfaces of the middle phalanx of the 5th finger and the proximal phalanx of the 1st finger, from which the corresponding tendon sheaths are opened. Longitudinal lateral incisions in the lower third of the forearm are used to open the Pirogov-Parony space. Using a guide line from a subclavian vein catheterization kit, perforated microirrigators with an internal diameter of 1.0 mm are passed through the opened lumen of the tendon sheaths of the 1st and 5th fingers in the proximal direction, and their ends are installed in the Pirogov-Parony cellular space.

The next stage of the operation is making incisions in the thenar and hypothenar areas, similar to those for isolated phlegmons of the aforementioned cellular spaces. In this case, it is possible to revise the flexor tendons of the I and V fingers and their sheaths almost along their entire length.

After washing the vagina with an antiseptic solution, necrectomy of all wounds, vacuuming and ultrasonic sanitation, each of the cellular spaces involved in the purulent process (thenar, hypothenar and Pirogov-Paron) is drained with polyvinyl chloride drainage tubes perforated in the middle part.

Treatment of combined phlegmon of the hand

The modified Zoltan approach is considered optimal for opening several cellular spaces on the palmar surface of the hand. In case of damage to the median palmar space and the thenar area, the incision is made parallel to or along the distal skin fold of the palm with an arcuate continuation along the thenar border into the proximal parts of the hand to the level of the wrist. In case of damage to the median palmar space and the hypothenar area, a similar approach is used, but turned around the longitudinal axis of the palm by 180°. Simultaneous damage to one or more interdigital spaces by a purulent process does not require additional incisions and does not affect the choice of the proposed approaches, since any of them provides sufficient exposure for revision of the interdigital cellular spaces. Moreover, after mobilization of the cutaneous-subcutaneous flaps from these approaches, revision and necrectomy are possible on most of the palm. The existing purulent abscesses on the back of the hand are opened with several arcuate incisions in accordance with Langer's lines.

These approaches are contraindicated in cases of significant wound defects in the area of the median palmar space due to the risk of developing necrosis of the mobilized skin-subcutaneous flap. In these cases, a T-shaped incision is preferable, the transverse part of which is carried out parallel to or along the distal fold of the palm, and the longitudinal part - from its middle in an arc through the existing wound to the level of the wrist. This approach, due to its longitudinal part, is less physiological than those described above, but when used in patients with primary wounds in the center of the palmar surface, the risk of developing skin necrosis is practically reduced to zero.

If the Pirogov-Parona space is involved in the purulent process, any of the above-described approaches should be continued to the level of the distal skin fold of the wrist joint, then along the fold to the radial edge of the lower third of the forearm, and completed with a longitudinal incision to open the phlegmon of the Pirogov space.

In case of phlegmon of the hand with the spread of pus to the forearm tissue above the square pronator, the arcuate access of Kanavel, continued onto the forearm, is preferable.

Necrectomy, especially in advanced cases, must be performed when the topographic relationships and anatomical integrity of the structural elements of the hand are disrupted, and it requires significantly more time and patience than surgical treatment of any isolated phlegmon.

For adequate drainage of postoperative residual cavities in the palm, two or three perforated tubes placed along the edges of the corresponding cellular spaces are usually sufficient. The interdigital spaces and the back of the hand involved in the process are always drained separately.

If the necrectomy performed is sure to be radical, primary sutures are applied to the skin. Remaining tissues in the wounds, diffusely soaked with pus (like honeycombs), areas of skin of questionable viability are considered a contraindication to wound suturing. In these cases, it is preferable to loosely fill them with gauze strips, abundantly soaked in water-soluble ointment.

The purulent process on the hand is most severe when all cellular spaces are affected simultaneously (total phlegmon). In this case, the approaches described above are used. However, one of the features of their course is the rather rapid development of skin necrosis on the back of the hand, which is diagnosed already upon admission of patients to the hospital. In these cases, it is justified to perform an arcuate incision through the necrosis zone with excision of the latter.

The peculiarity of surgical treatment of total phlegmons (due to the extensiveness of the lesion, diffuse purulent imbibition of the cellular tissue in the absence of clear boundaries of necrosis and unfavorable therapeutic background) is that it is practically impossible to perform a radical necrectomy at one time during the first operation. This determines the completion of the surgical intervention - primary sutures should never be applied to the wounds. All cellular spaces are subject to loose tamponade with gauze strips soaked in a water-soluble ointment. In the following days, such patients are shown daily staged necrectomy under anesthesia in the operating room. This tactic is completely justified and usually by 10-14 days it is possible to stop acute inflammation and begin to close the wounds by applying early secondary sutures or skin grafting.

Treatment of combined phlegmon of the hand

Surgical approaches for combined phlegmons of the hand should ensure revision of not only the finger structures, but also the spaces of the hand involved in the process, without violating the integrity of the vascular-nerve bundles and minimizing possible functional damage. That is why two access options are used for combined phlegmons of the hand, regardless of the type of panaritium. When the process is localized on the dorsal surfaces of the fingers and hand, an incision is made along the lateral neutral line of the affected finger with an arcuate transition to the back of the hand. When the palmar surface of the finger and hand is affected, an incision along the lateral neutral line of the affected finger is considered optimal, but with an arcuate transition to the area of the corresponding palmar eminence, and the affected cellular spaces on the palm are exposed by an S-shaped continuation of the existing palmar incision in the proximal direction. Purulent streaks on the back of the hand are opened with arcuate incisions along Langer's lines. Existing purulent wounds (entry gates or after previous operations) are excised sparingly according to Kosh, if possible involving them in the main access.

The principles of performing necrectomy were covered when describing the treatment of deep forms of panaritium and isolated phlegmon of the hand. Having completed the sanitation of the lesion, all anatomical structures and cellular spaces involved in the inflammatory process are drained with thin perforated polyvinyl chloride tubes. The principle of applying the drainage and washing system remains the same: the minimum number of drains should ensure drainage of residual cavities both on the fingers and on the hand. Synovial bursae and tendon sheaths, if preserved, must be drained separately. In cases of destruction of the sheath or synovial bursa, one or two drains in the subcutaneous tissue laid along the "exposed" tendons are sufficient. Also, joint cavities require separate drainage after interventions for arthritis or osteoarthritis, with microirrigators installed transversely in the interphalangeal joints and sagittally in the metacarpophalangeal joints.

In combined phlegmons with purulent process affecting the joints, postoperative management in the distraction mode is extremely important. Since the application of a distraction device in conditions of phlegmonous inflammation of soft tissues is impossible, it is optimal to use a spoke structure or a device for distraction of the metacarpophalangeal joints for this purpose.

If it is impossible to apply primary sutures to all wounds, it is advisable to apply them to individual defects that are clearly viable. Subsequently, small open wounds (up to 1.5 cm in length and up to 0.5 cm in width) quickly heal by secondary intention. Early secondary sutures are applied to larger wounds (up to 1.5 cm in width). In case of extensive wound defects, after the inflammation has been stopped, various types of skin grafting are used.

Total phlegmons of the hand, being the most severe forms of combined or combined phlegmons, require approaches similar to those described above. It should be noted that open wound management for total phlegmons is considered the method of choice.

The most malignant purulent process occurs on the fingers and hand against the background of diseases accompanied by pronounced microcirculation disorders. In these cases, open wound management is completely justified, which creates better conditions for sanitation and drainage and allows visual monitoring of the course of the wound process.