Felon

Panaritium (lat. Panaritium) - acute, purulent inflammation of the finger. Make up some local purulent processes that have an independent etiopathogenesis (infected fractures and dislocations, foreign bodies, burns, etc.).

In contrast to the domestic in the English-language literature, the purulent inflammation of the subcutaneous tissue of the nail phalanx of the finger is designated “felon”, and the remaining phalanges - “cellulitis”. Phlegmon of the hand (Greek phlegmone) - purulent inflammation of the cellulose that develops directly on the hand or due to the spread of the purulent process from the finger.

The peculiarity of the pathology is determined by the anatomical structure of the fingers. From the skin to the phalanges of the fingers are connective tissue webs, which delimit the purulent process when it occurs; but at the same time they are vehicles for deepening inflammation. The main cause of the development of felon are microtraumas.

Panaritium is a frequent pathology and is up to 30%. Outpatient treatment. To a greater extent, the incidence is observed in men engaged in work with irritants and the possibility of mechanical damage to the fingers. But purulent wounds of fingers do not belong to the category of felon.

Epidemiology

Panaritium in frequency ranks first among all purulent processes. From all primary patients referring to the surgeon, patients with felon and phlegmon of the hand range from 15 to 31%. Moreover, in recent years, a tendency to the growth of this pathology has been noted. The suppurative process complicates over 40% of minor injuries of the hand, which leads to microtrauma as one of the leading factors in the development of a severe purulent process on the fingers and hand.

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

Difficulties in treating felonut are associated with late treatment of patients for medical care, reduced effectiveness of antibiotic therapy, unreasonably long conservative treatment, and incorrect or insufficiently radical primary surgical intervention, which predetermines an increase in 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-radicalness of surgical interventions performed in polyclinics. Repeated operations in 25% of cases result in injury to the fingers and hand, leading to disability in 8.0% of patients. The highest percentage of unsatisfactory results was observed in the treatment of bone, tendon, articular, osteo-articular panaritium and pandactylitis, as well as combined and combined phlegmon of the hand. In 17-60% of patients with osseous panaritium, phalangeal amputations are performed. Unsatisfactory treatment results of pandactylitis also reach 60%.

[1], [2], [3], [4], [5],

What causes felon?

In recent years, under the powerful selective effects of antibacterial drugs, significant changes have occurred in the structure of pathogens that cause panarice. Staphylococcus and gram-negative bacteria belonging to the family Enterobacteriaceae or to an extensive group of so-called non-fermenting gram-negative bacteria came out on top. 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. An essential role is also played by obligate non-spore-forming anaerobic bacteria and conditionally pathogenic microflora. Rarely seeded beta hemolytic streptococcus. The frequency of mixed gram-positive and gram-negative microflora, as well as aerobic-anaerobic associations has increased.

In some patients, the infection on the hand progresses to the most severe pathology - anaerobic non-clostridial phlegmon of the upper limb. Of the variety of nonclostridial anaerobes should be allocated to the following clinically important groups: asporogenous anaerobic gram-negative bacilli (Bacteroides and Fusobacterium), anaerobic gram-positive cocci (Peptococcus and Peptostreptococcus) and gram-positive bacillus asporogenous (Actinomyces, Propionibacterium, Eubacterium).

In the majority of cases, felonut is the result of injury. 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 inflammatory process should be considered wounds from bites or bruises on the teeth. They are especially characterized by anaerobic and putrefactive infection.

Symptoms

The leading symptom of any felon is pain. The intensity of the pain varies from aching to unbearable; it can have a pulsating character, intensify at night and deprive patients of sleep. Because of the pain, patients almost always hold their sore hand in a sublime position. It is characteristic that in case of spontaneous breakthrough of pus, pain syndrome subsides considerably, which makes the patients a false impression of improving the condition of the finger. Almost simultaneously, edema of soft tissues increases, the severity of which can vary from engaging only the periungual roller with paronychia to a sharp thickening of the entire finger with tendovaginitis or pandactylitis.

Hyperemia is a fairly common symptom of panaritium, but it can be expressed slightly or even be absent in the deep forms of the disease. At the same time, local hyperthermia of the skin of the affected finger is almost always present. In the course of the development of the disease, the violation of the functions of the finger becomes apparent, especially the restriction of movements in it. This is most clearly manifested in deep forms of felon with involvement of the joints or tendons in the purulent process. The development of felon is often accompanied by a deterioration in the general condition of patients, fever, weakness, malaise. These phenomena are especially pronounced in lymphogenous complications of the local inflammatory process.

Skin felon is a collection of pus between the epidermis and the skin itself and manifests itself as a characteristic “bubble” syndrome with accumulated purulent exudate, often complicated by lymphangitis.

Paronychia - inflammation okolonogtevogo roller. Often occurs after a manicure or deburring. Typical edema, hyperemia of the skin and tenderness in the area of the periungual roller. With the seeming simplicity of treatment of this pathology in some cases, the disease may acquire a chronic course. There is a proliferation of granulations in the zone of the base or edge of the nail plate (the so-called wild meat) with a long serous-purulent exudation, which can later lead to the development of bone destruction of the nail phalanx.

When subungual felon occurs the accumulation of purulent exudate under the nail plate. As a rule, it occurs as a result of the progression of the purulent process during paronychia or after the injection under the free edge of the nail.

Subcutaneous felon - purulent-destructive inflammation in the subcutaneous tissue. 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 “honeycomb” type of structure of the subcutaneous tissue, interstitial pressure quickly increases and necrosis occurs even without free purulent exudate.

The synonym of tendinous felon - purulent tendovaginitis. The characteristic symptom complex, caused by the accumulation of purulent exudate in the narrow space of the tendon sheath, occurs during the primary microtrauma of the vagina flexor tendons or as a complication of subcutaneous felon. Accurate diagnosis is helped by point palpation of finger tissue with a bell-like probe, which reveals maximum pain along the affected tendon.

The development of destructive changes in the bone-based finger is the basis of bone felon. It occurs as a complication of another form of felon or after extensive injury with bone damage. The clinical picture varies from congestive tissue edema with fluctuation, hyperemia and soreness in acute inflammation to practically painless lesion of the phalanx with the presence of purulent fistula. The difficulty is that the x-ray signs of bone destruction are “late” from real changes in the bone tissue for 7–12 days, which is a frequent cause of late diagnosis.

Joint arthritis occurs due to the progression of subcutaneous and tendon felon or after injury with a primary injury to the interphalangeal joint. The clinical picture is dominated by signs of acute inflammation with a characteristic swelling in the area of the affected joint, tenderness and hyperemia. Movement in the joint and axial load on it are sharply painful. On the roentgenogram quite often reveal the characteristic narrowing of the joint space.

Osteo-articular panaritium is usually the result of articular panaritium with improper treatment of the latter. In the diagnosis of the disease, one of the most important clinical signs is the appearance of pathological lateral mobility and crepitus in the joint. It is also important the presence of characteristic features on the radiograph (narrowing of the joint space in combination with foci of destruction in the articulating articular ends).

Pandaktilit - the most severe purulent pathology of the finger brush. Characterized by the defeat of all the anatomical structures of the finger (skin, fiber, tendons, bones and joints). Occurs or due to the progression of felon, or after extensive trauma to the finger with damage to all anatomical structures. The cardinal difference from osteo-articular panaritium is extensive destructive changes in at least one of the tendons, which require partial or complete resection of the latter. Often, when pandactylitis is preserved, the finger cannot be preserved; therefore, phalanges or the finger as a whole are amputated.

Classification of felon

Depending on the localization of the abscess, panaritium is divided into superficial and deep. Deep felon, as a rule, is a superficial complication of their improper treatment, high microflora virulence, the presence of comorbidities that aggravate purulent processes (diabetes, vitamin deficiency, immunodeficiency, cancer) and reduce the body's resistance.

Surface felon

Common manifestations for all forms of surface felon are: pain in the finger arching or jerking character; edema and hyperemia with blurred edges, extending to the entire finger, but most pronounced in the area of the abscess; painful contracture of the finger, violating the function of the entire hand. Against this background, characteristic for each species of panaritium signs are determined, allowing to differentiate its shape.

1. Cutaneous felon. Against the background of swelling and hyperemia of the finger, intradermal blisters (one or several) are formed, filled with pus. When performing the operation, you need to be wary about the "spotted" felon when there is a deep abscess, which has opened with a fistula into the skin.
2. Subcutaneous felon. Localization of abscess in the form of an abscess in the subcutaneous tissue. Predominantly affected nail phalanxes. Edema and hyperemia common, but over the area of the abscess often forms a whitish area. Localization of the abscess is determined by the probe (“the finger is not palpable with a finger!”) According to the maximum pain.
3. Okolonogtevoy Panhartsy (paronychia). Occurs more frequently after performing a manicure, disrupting skin burrs. The abscess is localized in okolonogtёvym torsion or on the side surface of the nail. The microflora can be typically purulent or fungal, which happens most often.
4. Subungal felon. It develops more often with an existing paronychia, when pus penetrates from the periungual torsion under the nail. Diagnosis is not difficult, as the pus shines through the nail.

Deep felon

Primarily develop very rarely and in most cases are a complication or outcome of surface felon.

1. Tendinous felon. Purulent inflammation of the tendon itself is very rare. More often it is its transient, reactive inflammation, as exudative, with marked edema and incarceration in the tendon sheath. This explains the urgency of the care, as the tendon can necrotize. An emergency patient should be referred to a hospital with an ambulance. The clinic is pronounced: the finger is set bent; attempts to straighten it cause a sharp pain; palpation of the tendon in the Pirogov space and abdominal muscles 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, above it appears reddening of the bluish color, the finger acquires a "spindle" shape.
3.  Bone felon. Most often the nail phalanx of the first finger is affected. He acquires a "club-shaped" form. On radiographs revealed bone destruction in the form of an osteomyelitic process.
4. Pandaktilit - purulent inflammation of all tissues of the finger.

Complications of felon

1. Distribution of the purulent process in the distal regions with the development of abscesses or phlegmon of the hand and Pirogov space. Leak with a typical Clinic. Localization of ulcers zpi-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 the venous vessels with the development of thrombophlebitis and periflebitis is rare, but requires hospitalization.

[6], [7]

How to recognize felon?

Establishing a diagnosis of felon for a practitioner on the basis of a combination of anamnestic and clinical signs usually presents no difficulties. It is much more difficult and extremely important at the preoperative stage to establish the type of felon, which largely determines the surgical tactics. In this regard, the following diagnostic algorithm is justified in the study of each clinical case:

• a thorough history taking (the nature and duration of the primary injury or microtrauma, the treatment carried out, the presence of comorbidities);
• evaluation of the results of an objective examination (the type of the affected finger, changes in the skin, localization and severity of pain during point palpation with a bell-like probe, the presence of pathological mobility in the joint or bone cremation, etc.);
• X-ray data analysis of the affected finger.

[8]

Differential diagnostics

Given the greater activity and contact of the hand, on the fingers can form boils, carbuncles, anthrax carbuncles, which are not difficult in the differential diagnosis. More often panaritium has to be differentiated from erysipyloid ("swine erysipelas") caused by a specific stick. Infected when cutting raw meat (usually pork) or fish.

A distinctive feature is bluish hyperemia, with clearly defined boundaries.

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

How to prevent felon?

Reducing industrial and domestic injuries is considered the most effective method of prevention of felon. Full rehabilitation of minor skin lesions, timely execution of primary surgical treatment of wounds reduce the risk of purulent complications to a minimum.

[13], [14]

What is the prediction of felon?

Timely and complete treatment of felon allows us to state a favorable prognosis for patients' lives.