Treatment of panarisis

The treatment of panaritium pursues the goal of complete and lasting relief of inflammatory phenomena while minimizing functional and aesthetic negative consequences, and in some cases, the risk of a fatal outcome.

Indications for hospitalization

Outpatient treatment is possible only for superficial forms of panaritium. All patients with deep forms of panaritium and phlegmon of the hand should be hospitalized. Surgical treatment (sometimes repeated) and the postoperative period, at least until the acute inflammation subsides, should be carried out in a hospital setting.

Surgical treatment of panaritium

Preoperative preparation includes washing the affected hand with warm water and soap. Worthy of attention is the technique of intramuscular administration of a broad-spectrum antibiotic 30-40 minutes before surgical treatment of panaritium, which limits the spread of infection and promotes a smoother course of the postoperative period.

Treatment of various forms of panaritium

Paronychia

The periungual fold is mobilized by one or two (depending on the extent of the process) longitudinal incisions. After necrectomy and sanitation, a gauze strip with hydrophilic ointment should be inserted between the fold and the nail plate so that the skin fold is turned back and the remaining exudate can freely evacuate. With proper treatment of panaritium, the inflammation usually subsides within 2-3 days.

Subungual and cutaneous panaritium

Resection of only the part of the nail plate exfoliated by pus is indicated, since the erosive surface of the nail bed is extremely painful during dressings when the nail is completely removed. The entire nail plate is removed only when it is completely exfoliated. Subsequently, the surface deprived of the nail is treated with a solution of potassium permanganate until complete epithelialization.

In case of cutaneous panaritium, the epidermis exfoliated with pus is excised, which does not require anesthesia, and a thorough revision of the erosive surface is performed, since it is possible for the necrotic process to spread deeper, through a narrow passage, and the formation of a subcutaneous panaritium of the “cufflink” type.

Subcutaneous felon

Due to the peculiarities of the structure of the phalanges of the fingers, it is not enough to limit surgical treatment to a skin incision only, as this leads to the progression of the purulent process into the tissue depths with the development of a bone or tendon panaritium. Therefore, treatment for subcutaneous panaritium must necessarily include necrectomy - excision of all necrotic tissue. If you are confident that the necrectomy has been adequately performed, it is permissible to complete the treatment by applying a drainage and irrigation system with primary sutures. If you are not sure, it is advisable to leave the wound open, loosely filling it with a gauze strip with a water-soluble ointment. After cleaning the wound and stopping the acute inflammation, the treatment of panaritium consists of closing the wound with secondary sutures or aligning its edges with strips of adhesive tape.

Tendinous felon

Panaritium requires emergency surgical treatment, since compression of the tendon by exudate quickly leads to necrosis of the delicate tendon fibers. Treatment for tendon panaritium depends on the condition of the subcutaneous tissue adjacent to the tendon sheath.

In case of intact tissue (in case of tendovaginitis development after injection directly into the tendon sheath), surgical treatment is limited to incisions and opening of the tendon sheath in the distal (on the middle phalanx) and proximal (in the projection of the head of the corresponding metacarpal bone) sections. After evacuation of the exudate and washing of the vagina with antiseptic solutions, its cavity is drained along the entire length with a perforated microirrigator, and the skin edges of the wound are sutured with atraumatic thread 4/0-5/0.

In cases where the subcutaneous tissue is also involved in the purulent-destructive process, a longitudinal incision is made along the lateral surface of the finger with an arcuate extension onto the palm in the projection of the "blind sac" of the tendon sheath. The skin-subcutaneous flap is dissected from the sheath, which is usually partially or completely necrotic, preserving the palmar vascular-nerve bundles and performing a thorough necrectomy in the subcutaneous tissue, excising the non-viable areas of the tendon sheath and necrotic tendon fibers. The tendon is excised completely only in the case of obvious necrosis, when it is represented by a structureless mass. After applying a drainage-washing system, treatment of panaritium consists of filling the wound with gauze strips with a water-soluble ointment. Closing the wound in one way or another is possible only after the acute inflammation has been relieved and there is confidence in the viability of the tendons.

Bone felon

The treatment tactics depend on the severity of inflammation in the surrounding tissues. If the disease lasts for a long time, there are formed fistulas through which purulent exudate is drained, inflammation in the skin and subcutaneous tissue is usually not expressed. In this situation, radical necrosequestrectomy is performed, pathological granulations in soft tissues are removed and the wound is closed with primary sutures with or without a drainage and washing system (if the cavity is small). It should be noted that extensive bone resection is not performed.

The affected bone tissue is gently scraped out with a sharp bone spoon, which is usually sufficient to remove avascularized necrotic areas. In the case of sequestration of the phalanx, only freely lying sequestra are removed, preserving the main bone mass.

If there is subcutaneous tissue with severe acute inflammation above the affected bone, it is advisable not to suture the wound after sequestrectomy, since further progression of purulent inflammation in soft tissues is possible. The wound is washed with antiseptics, loosely filled with a gauze strip with water-soluble ointment and left open until acute inflammatory phenomena are relieved.

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Articular and osteoarticular panaritium

In surgical treatment of articular or osteoarticular panaritium, the approach is usually performed from the dorsal surface of the finger in the projection of the corresponding joint (Z-shaped). Arthrotomy, revision of the joint cavity and removal of purulent exudate are performed. In the absence of foci of destruction in bone tissue, the joint cavity is sanitized with antiseptic solutions. The joint cavity is drained with a perforated microirrigator, and the skin wound is sutured (in the absence of acute inflammation in the soft tissues). If bone destruction is detected, the affected areas are scraped out with a sharp bone spoon, and the joint cavity is drained. Further decompression in the joint is considered an extremely important point in the treatment of this pathology, since otherwise progression of destruction is possible. Decompression is performed in various ways: traction with a modified Kirschner wire for a silk loop placed on the nail plate; a device developed for distraction of the joints of the hand; application of a distraction apparatus. As a result, intra-articular pressure decreases, diastasis occurs between the articular ends, which helps to relieve inflammation in the joint and prevents the formation of adhesions in the joint cavity. However, application of a distraction apparatus is possible only in the absence of inflammation in the soft tissues of the articulating phalanges in order to avoid the development of complications associated with the passage of needles through inflamed tissues.

Pandactylitis

The complexity of treating this pathology is that it simultaneously contains, to one degree or another, signs of all the above-mentioned diseases. At the same time, the risk of losing a phalanx or a finger as a whole is extremely high. However, with the right approach to treating this pathology, saving the finger is quite possible.

The incision is made along the lateral surface of the finger with an arcuate extension to the palmar surface of the hand in the projection of the head of the corresponding metacarpal bone. The palmar cutaneous-subcutaneous flap is dissected from the flexor tendons with preservation of the vascular-nerve bundles, the dorsal flap is treated in a similar manner. Both flaps are unfolded, providing good access to all finger structures. Difficulty arises only during revision of the area of the dorsolateral surface of the main phalanx of the finger on the side opposite the incision. Access to this area, if necessary, is carried out from a separate arcuate incision on the back of the hand in the projection of the metacarpophalangeal joint. A thorough necrectomy (sequestrectomy) is performed, the wound is sanitized with antiseptics. The tactics of completing surgical treatment for pandactylitis, as with other types of panaritium, depends on the severity of inflammatory phenomena in the soft tissues. Surgical treatment can be completed by applying a drainage and irrigation system and primary sutures only if there is complete confidence in the adequate execution of necrectomy, which, as a rule, is achievable only under the condition of subacute purulent inflammation in the subcutaneous tissue. In conditions of acute inflammation, the wound is filled with gauze strips with a water-soluble ointment and left open. Subsequently, the condition of the tissues is monitored during dressings, and, if necessary, a staged necrectomy is performed. Decompression in the joint is carried out according to indications, most often by traction of the nail plate with a Kirschner wire. As the inflammation subsides and the wound is cleansed, treatment of panaritium consists of closing the wound with secondary sutures or one of the types of skin grafting.