Phlegmon of the foot

Phlegmon feet - purulent processes, purulent inflammation of the tissues of the fingers is traditionally called an abscess.

ICD-10 code

L.03.0. Phlegmon of the foot

What causes the phlegmon of the foot?

The entrance gates of the infection are defects in the skin, which, as a rule, arise after various mechanical damages to the skin. It can be nyxes and cuts, rubbing (a prolonged traumatic effect of tight shoes combined with high moisture from sweat), as well as damage to the epidermis in the deep folds between the fingers, caused by a fungal lesion. The further development and spread of infection depends on the pathogenicity of the microflora, the resistance of the organism and the anatomical features of the area of injury.

More often the phlegmon of the foot is caused by staphylococci, much less often - streptococci, Pseudomonas aeruginosa and Escherichia coli, proteus. In 15% of cases, a mixed microflora is detected. Pathomorphology and pathophysiology of the process are directly related to the anatomy of this area and the pattern of infection spreading to neighboring anatomical zones.

Anatomy

Anatomically on the foot, three departments are distinguished: tarsus, metatarsus and phalanges of fingers. In clinical practice, it is also conventionally divided into three departments: anterior, middle and posterior.

The anterior section unites the phalanx of the fingers and metatarsal bones; middle - scaphoid, cuboid and sphenoid bones; posterior - talus and calcaneus.

Bones of the middle section take part in the formation of three functionally important joints: Tar-heel-navicular, five-hedge-cuboidal and navicular-wedge-shaped. The articular lines of the Taranno-Pentogno-navicular and Pentagon-Cuboid Joints look like a horizontally turned eight. The cavities of these joints are completely detached, however, in surgery during surgery, they are conditionally taken for one joint and called Shoparov. The key of the shopar joint is a powerful bifurcation ligament located between its two components.

Slightly distal than the navicular bone together with the three wedge-shaped joints forms the joint, which is connected with the wedge-cuboidal and tarsal-metatarsal joints. The border between the anterior and middle sections is the tarsus-metatarsal or Lisfrankov joint. The key of the Lisfrankov joint is a strong ligament located between the medial wedge and II metatarsal bones. The intersection of key ligaments is the defining moment of the isolation operations.

Under the skin of the back side is the rear fascia. It continues the fascia fascia and attaches to I and V metatarsal bones. Deep fascia covers metatarsal bones and dorsal interosseous muscles. Between the rear and deep fascia there is a fascial space of the rear that accommodates the tendons of the extensor muscles, vessels and nerves. The tendons of the extensor muscles have their own tendon sheaths, covered with the upper and lower retainers of the extensor muscles. The fascial space of the rear communicates with the anterior osteo-fibrous vagina of the shin.

Under the skin of the plantar area from the heel of the calcaneus to the heads of metatarsal bones lies the plantar aponeurosis, which has in the distal sections commissural openings. Through them, the subcutaneous tissue of the soles and toes communicates with the medial fascial space. From the aponeurosis inward aponeurotic septa are directed. Two partitions and an interosseous fascia all the subpanoneurotic space is divided into three sections.

Medial fascial space of the sole, containing short muscles of the thumb. Outside, it is delimited by the medial intermuscular aponeurotic septum (attached to the calcaneal, navicular, I cuneate and I metatarsal bones), and in the proximal direction ends blindly, without communicating with the fascial spaces of the shin.

The lateral fascial space of the sole, containing the muscles of the V finger. On the inside, it is delimited by the lateral intermuscular aponeurotic septum (attached to the V metatarsus and the vagina of the tendon of the long fibular muscle). In the proximal direction, just like the medial, ends blindly.

The medial fascial space of the sole, containing a short flexor and tendons of the long flexor of the fingers, as well as vessels and nerves. From the inner and outer sides it is delimited by the medial and lateral intermuscular septa respectively; from the sole side - plantar aponeurosis and in the depths - with interosseous muscles and a deep fascia covering them. In the proximal direction it communicates with the deep fascial space of the shin through three channels: plantar, heel and ankle.

[1], [2]

Ways of spreading the infection

When choosing the right operative access, it is important to clearly identify possible routes of infection from the primary focus to the nearby anatomical areas.

The phlegmon of the foot can spread:

• in the distal direction - on the fingers and fascial spaces of the plantar area;
• in the proximal direction - on the anterior fibrotic fibrous vagina of the shin.

The medial fascial space of the sole (the most frequent localization of the infection) communicates with several nearby anatomical regions.

In the distal direction: through the commissural openings - with the subcutaneous tissue of the sole; along the channels of the vermiform muscles - with the interosseous and fascial spaces of the rear.

In the proximal direction: through the plantar, heel and ankle canals - with a deep fascial space of the shin.

In the medial direction: along the tendon of the long flexor of the thumb - with the medial fascial space of the sole.

In the lateral direction: along the flexor tendon - with the lateral fascial space of the sole.

How does phlegmon appear and foot abscesses?

Abscesses of the fingers are accompanied by local hyperemia and swelling, as a rule, easily diagnosed. Abscesses of the distal part of the fingers do not tend to spread in the proximal direction.

The phlegmon of the foot of the back

The infection can penetrate directly through the damaged skin in this area or spread from the sole through the channels of the vermicular muscles or directly through the intergluteal spaces (unlike the phlegmon of the hand). The phlegmon of the foot is characterized by a bright hyperemia of the skin with clear edges, very similar to erysipelatous inflammation. The skin acquires a characteristic luster, the edema grows and spreads beyond the zone of hyperemia. It is possible to extend the process to the anterior fascial space of the shin.

Subcutaneous (epifascial) phlegmon of foot

Superficial phlegmon of foot (abscess) soles, as a rule, has traces of skin lesions and minor local swelling and tenderness. Usually, there are no difficulties with recognition and differential diagnosis with other phlegmon. Spontaneous pain occurs in epifascial purulent processes only when lymphangitis or thrombophlebitis joins. Hyperemia of the skin with all plantar phlegmon is not expressed due to the thickness of the epidermal layer. Tendencies to spread to other anatomical zones, as a rule, do not.

Phlegmon of the foot of the medial cell space

Such an isolated phlegmon of the foot is rarely recognized, only at the earliest stages of its development. Later, through the openings in the medial intermuscular aponeurotic septum along the tendons that are perforating it or during its melting, the pus can spread into the median cell space and very rarely in the proximal direction.

The phlegmon of the foot of the medial cell space, in contrast to other sub-panoneurotic phlegmon soles, is characterized by the appearance of swelling (in this part the aponeurosis is the thinnest), but skin hyperemia is not expressed. Painfulness at palpation at any point of the sole is a sign of the spread of the process into the middle cellular space.

The phlegmon of the foot of the lateral cellular space

Identify such a phlegmon in its primary nature, as well as medial, can only be found in sufficiently early stages of development. The phlegmon of the foot quickly spreads to the middle cell space.

Differentiated phlegmon of the foot from others of the same area is extremely difficult due to meager symptoms. There is no swelling, flushing and fluctuation. Soreness in palpation with a button probe in the lateral region of the sole may be the only symptom of the disease.

The phlegmon of the foot of the median cell space is the most common of all plantar phlegmon. A rapid melting of the intermuscular aponeurotic septum is characteristic. It often occurs due to the spread of phlegmon medial and lateral fascial spaces to the middle one. Characteristic pulsating pains, sharply increasing when palpation of any part of the sole. Leather soles, as a rule, in color is not changed, there is no edema and fluctuation. Scant symptoms of the inflammatory process are explained by the presence of a powerful plantar aponeurosis and a large thickness of skin in this area. Changes can be detected only by careful comparison of a sick and healthy feet. The general condition is heavy, with a high temperature. Characteristic of significant edema and hyperemia of the rear (inflammation spreads between the bases of I and II metatarsal bones). Typical distribution through the ankle canal to the deep fascial space of the shin. In this case, there is hyperemia, edema and sharp soreness in palpation in the space between the Achilles tendon and the medial malleolus (the area of the ankle canal), and later the edema of the shin is combined with its sharp soreness.

Combined phlegmon of foot

The most frequent variant of flow phlegmon. The phlegmon of the foot of the medial and lateral space of the soles is most often combined with the phlegmon of the middle space (due to the communication between the spaces), which is prone to spread to the rear.

[3], [4], [5], [6], [7],

Tendovaginitis

Acute suppurative tenosynovitis of the rear are rare, they occur with direct damage if the wound is located along the tendons of the extensor muscles. Usually the process is not limited to tendinous vaginas and affects all interfascial space; the phlegmon of foot is formed. Infection can spread into the anterior fascial space of the shin.

More often there are tendovaginitis tendons of flexor muscles in the plantar area. The cause is a direct damage to the tendon sheaths that lie close to the skin of the plantar surface of the fingers and is most accessible to infection. In the place of damage, the finger becomes sharply edematous and hyperemic. Characterized by acute pulsating pain, amplified by palpation with a probe probe with localization along the course of the corresponding flexor muscles. Of particular importance is the tenosynovitis of the flexor of the thumb, as the purulent process quickly destroys the proximal end of the vagina and penetrates into the medial cell space, and thence into the middle cellular space with the development of a combined subponeurotic phlegmon of the sole.

Chronic tenovaginitis occur less aggressively, appear much more often acute (with repeatedly repeated damage), and treatment in most cases is conservative.

Purulent arthritis

Purulent inflammatory processes in small joints are rare, and in most cases it is difficult to determine the primary nature of the lesion. In the literature there are indications of the possibility of developing purulent arthritis as a complication of infectious diseases (gonorrhea, syphilis and brucellosis). Sometimes purulent arthritis of small joints occurs after bruises.

First, there are pains in the foot, intensifying with static and dynamic load. After a considerable period of time, edema and hyperemia appear, mainly at the rear. On the roentgenogram, there is a pronounced osteoporosis of the tarsal bones of the tarsus and proximal heads of metatarsal bones, a sharp expansion of the joint cracks. The largest destructive changes are usually determined in the region of navicular-wedge-shaped and wedge-metatarsal joints.

Osteomyelitis

Osteomyelitis of bones can develop as a complication of open fractures or as a result of the spread of purulent process to the bone from the soft tissue side. When hematogenous osteomyelitis is affected mainly large bones - heel and talus. It is characterized by an acute onset of the disease, an increase in temperature to 39-40 ° C, and local soreness in palpation. On the roentgenogram, changes occur on the 10-14th day: a thickening of the osteoporosis. Occasionally during this period, radiographs can reveal sequestrants, but the spongy structure of the most frequently affected bones makes it difficult to diagnose them.

Classification of purulent-inflammatory diseases

Clinical classification of purulent-inflammatory processes (constructed in accordance with anatomical principles).

• Abscess of the finger.
• The phlegmon of the foot is the back.
• Phlegmon foot of the plantar side:
  • subcutaneous (epifascial) phlegmon of the foot;
  • medial, lateral and median cell spaces;
  • combined phlegmon of foot;
• Tendovaginites.
• Purulent arthritis.
• Osteomyelitis of bones.

[8], [9], [10], [11], [12]

How is the phlegmon of the foot treated?

The objectives of treatment for abscesses of fingers and phlegmon:

• provide an adequate outflow of purulent exudate;
• prevent the spread of infection (with the help of radical necrectomy);
• create favorable conditions for healing with minimal functional and aesthetic impairments.

Surgical treatment is performed against the background of antibacterial therapy (taking into account the antibiotic susceptibility of the causative agents of the infection). Anesthesia and detoxification are indispensable conditions for successful treatment in the early stages. Operations on the foot are performed under a conductive anesthesia. The foot must be ischemic, placing a cuff on the lower third of the calf from the tonometer and rapidly injecting air to 150-200 mm Hg. During the acute period, immobilization and ankle joint is necessary.

With abscesses of the fingers and phlegmons of the rear, outpatient treatment is possible. In case of subthoroneurotic processes, arthritis and osteomyelitis urgent hospitalization is necessary because of the threat of proliferation of the purulent process in the proximal direction and to deeper anatomical structures.

Incisions in abscesses of the fingers are performed above the place of the greatest soreness, which is detected by palpation with a buttoned probe. For a wide opening of the purulent foci, arched or stitch-like incisions are made, allowing to completely excise necrotic tissues. Treatment continues in accordance with the general principles of purulent wounds. When localizing abscesses on the main phalanx, one should remember about the possibility of spreading the infection to the area of inter-palatal spaces and the medial fascial space of the sole through the channels of the vermiform muscles, therefore, if necessary, the incisions are widened in the proximal direction. For the opening of the back phlegmon, longitudinal incisions are made away from the rear artery. In this case, cut the skin, the back fascia, remove pus and necrotic tissue and drain the cavity formed. After adequate necrectomy, it is possible to complete the operation by applying a drainage and rinsing system and primary sutures,

The widespread subfascial phlegmon of the foot of the rear is treated with the help of a cut along the entire length, and when the tendon sheaths are involved in the process, dissect the cruciform ligament.

When involved in the purulent process of the anterior fascial space of the tibia, the incision is made along the anterior surface of its middle third, 2 cm outward from the crest of the tibia. After dissection of the skin, subcutaneous tissue and dense fascia through the muscles (between the anterior tibialis muscle and the long extensor of the fingers) penetrate into the perivascular tissue. With the widespread process for full drainage, the contra-percutaneous incisions are made through the entire muscular mass of this area. When revising the purulent cavity, the interosseous septum is necessarily examined: if pus penetrates through the holes or defects in it, it is necessary to open and drain the posterior fascial space of the shin.

With epifascial phlegmon soles, it is sufficient to make a small incision above the place of the greatest swelling and soreness, radically sanitize the abscess and complete the operation by applying a drainage-rinsing system (the ends of the perforated polyvinylchloride tube are removed through punctures in healthy skin) and primary sutures to the skin.

To open the medial space, the Delorme incision is more often used in the distal half of the projection of the first metatarsal bone, respectively. Since the infection of this space is prone to rapid spreading, when pus enters through defects in the medial intermuscular septum, surgical intervention is supplemented by opening the middle cellular space.

When the phlegmon of the lateral space is opened, the Delorme incision is performed in the distal half, respectively, of the projection of the IV metatarsal bone. After evacuation of pus, necrectomy and sanation of the wound, a lateral intermuscular septum is examined. If pus comes through defects in it, it is necessary to open the middle cellular space additionally.

One midline incision on the foot in the projection of III metatarsal bone may not be enough, since the closing of the edges of the incision of the plantar aponeurosis and muscles leads to a violation of the outflow of pus. For adequate opening and draining, it is advisable to perform two lateral incisions in the projection of the vertical bone-fascial bridges of the sole, then to excise the necrotic sites of the lintels, creating conditions for a better outflow of pus, and to drain the tube to the deepest part of the middle space.

When purulent swabs are found in the interdigital spaces, the abscess is supplemented with a transverse incision in the distal part of the sole, in the region of the distal heads of the metatarsal bones (Figures 33-6), and in the process of transition to the rear by the contra-percuticular incisions at the rear, usually between the II and III metatarsal bones .

When pus spreads into the deep fascial space of the tibia (in the course of the tendons of the flexors and the posterior bulbous fibrocarhicular bundle through the ankle canal) it is necessary to open it. An obvious and frequent sign of proximal infection is the appearance of pus in the subponeurotic space of the sole with pressure on the lower third of the shin and the internal (medial) anterior region. In this case, it is necessary to open the deep fascial space of the shank with a cut along the inner surface in its lower third, retreating 1 cm from the inner edge of the tibia. After opening the superficial fascia, the soleus tendon is moved backwards and to the side, exposing and dissecting the inner fascia, and then dissecting the deep phlegmon. Unfortunately, such a separate opening of the deep fascial space of the shank and subaponeurotic space can lead to necrosis of tendons of the flexor muscles of the ankle canal area. In these cases, a single incision is preferred, which opens access to the submaxoneurotic space, the inner ankle canal and the deep fascial space of the shin. The above sections are combined by dissection of the anterior wall of the ankle canal.

Surgical treatment of a combined phlegmon includes elements and peculiarities of the technique of interventions on each of its components.

In acute purulent tendovaginitis of extensor, surgical treatment, if necessary, consists in opening the fascial space of the rear. When the tendons of the flexors are damaged, the affected tendon sheath is immediately opened, as in these cases the necrosis of the tendons develops quickly and the purulent process spreads to the neighboring anatomical areas.

Surgical treatment of purulent arthritis depends on the localization and extent of involvement in the soft tissue process. More often, the phlegmon of the foot of the back is opened. Having opened a deep fascia of the rear of the foot and providing good access to the joints, the affected bone structures are treated with a Folkman spoon and a flow drainage-washing system is installed with the application of primary seams to the skin. After 8-12 days drainage is removed, and the immobilization of the foot is saved for another 10-12 weeks.

In the treatment of acute hematogenous bone osteomyelitis, antibiotic therapy is now given priority. If the de-escalation principle of antibiotic therapy is observed, by the 2nd-3rd day the body temperature will be normalized, the pain will cease and the sequestration process will stop. The presence of sequesters and fistulas is an indication for surgical treatment (radical sequestrectomy) in accordance with the general principles of osteomyelitis treatment. In the osteomyelitis of the calcaneus, an incision is made from the Achilles tendon to the anterior margin of the bone through the entire thickness of the soft tissues. The bone is scraped and cleaned from the inside, trying not to damage the cortical layer. Free-lying cortical sequesters are removed by scraping the residual cavity with a sharp spoon and sewing the soft tissues over the drainage laid in the formed bone defect. When osteomyelitis of the talus bone, anterior or posterior arthrotomy is performed with the sanation of the pathologically altered bone structure. With total defeat of the talus bone, astragalectomy is performed.

Secondary forms of osteomyelitis, in contrast to hematogenous, are less acute, develop slowly and are not accompanied by large destruction of bone structures.

In the postoperative period, antibiotic therapy in combination with anesthetics is indicated. Mandatory immobilization of the plantar gypsum langete for 4-5 days before the removal of acute inflammation in soft tissues.

What prognosis does the phlegmon have?

After the opening of purulent foci on the fingers, the phlegmon of the foot has a favorable prognosis. After operations on the bones for osteomyelitis, an orthopedic consultation is shown to decide whether to wear special shoes.