Treatment of hand phlegmon

The diagnosis of "phlegmon brush" - an absolute indication for emergency or urgent surgical treatment. The task of preserving the brush function should be in front of the surgeon from the very beginning. Even before the cut is performed on the brush, you should think about which zone and what the scar will be, to what extent it will affect the brush function. The incisions are made taking into account the Langer lines corresponding to the natural cutaneous folds. It should be specially noted that the execution of large longitudinal incisions is unacceptable. Operational access should be as short and as sparing as possible. Creation of wide access is possible by modifying the cut according to the type of S-shaped, arc-shaped or broken, remembering that the scar strands the tissues along the length. Slits "through all layers" are not permissible for opening a purulent foci. Only the skin is dissected by a scalpel. All further manipulations on the tissues are carried out using clamps and hooks, which allows you to visualize and preserve all the important structures in the functional sense (vessels, nerves, tendons). The presence of an assistant in the operation on the brush is mandatory.

The next stage of the operation is a careful necrosectomy, in which the purulent focus should be excised by the type of primary surgical treatment. During the performance of necrectomy, the vessels and nerves actually skeletonize. Do not resect the affected tendon, if you can restrict the removal of individual necrotic fibers. Necrectomy on bone and articular structures should include the removal of only sequestered sites. Interventions on the joints with purulent arthritis or osteoarthritis should be conducted in the postoperative period in the mode of distraction, which is often provided with traction modified with a Kirschner knitting needle or with the help of a special device.

After necroctomy and haemostasis, each cell space is drained with a separate perforated polyvinylchloride tube, which is fixed to the skin with a separate suture. After intervention on joints and tendon sheaths, these structures require additional drainage. Wounds are treated with an antiseptic, evacuated and treated with low-frequency ultrasound in an antibiotic solution.

Performing a radical necrectomy and adequate drainage of the residual purulent cavity allows the operation to be completed by the application of primary sutures to the wound. Wound repair is performed with atraumatic threads 3 / 0-5 / 0. In case of severe damage to the brush, the use of micro irrigators and partial suturing of the wounds is supplemented by the imposition of gauze dressings impregnated with ointment on a hydrophilic basis.

If there is no possibility of instantaneous suturing of the skin defect, different types of skin plasty should be used more widely. In cases of nude tendons or bones, it is possible to use non-free skin plasty according to the type of the Italian, crosswise from the finger to the finger or a flap on the vascular pedicle. Granulating defects are preferable to cover with a free split skin graft. All plastic surgeries are performed after relief of acute purulent inflammation, but at the earliest possible time.

An important point after the operation on the hand is proper immobilization with the observance of measures for the prevention of maceration of the skin. The timing of immobilization of the operated on the purulent process of the brush should be limited to the cessation of acute inflammatory phenomena.

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

Treatment phlegmon in the interdigital space

When a purulent process involves a single interdigital space on the palmar surface of the hand, an arcuate Bunnell incision is made at the level of the head of the metacarpal bones. At the rear of the hand, a contourpert incision is made in the projection of the corresponding gap. Wounds are connected with each other and drained through a perforated micro irrigator with overlapping of primary seams. When two or three interdigital spaces are affected, one arcuate incision of the skin is made on the palmar side of the hand parallel to the distal transverse fold. On the rear of the hand, separate incisions are performed, as in the case of a lesion of one interdigital space, but in an amount corresponding to the number of gaps involved in the purulent process. All back wounds are connected with a cut on the palmar surface. Through each interdigital space, a micro irrigator is carried out, and another tube is laid on the bottom of the palmar wound in the transverse direction.

Treatment of phlegmon of the area of tenar

Operative access is an arcuate incision up to 4 cm long, parallel to the skin fold of the tenar and somewhat 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. On the rear of the hand, in the zone I of the interdigital space, a contour-percut arcuate incision is performed. After performing necrectomy and sanitation of the wound, the cavity is drained with two perforated tubes, one of which is carried along the inner edge of the tenar area, and the second one is along the main incision on the palmar side of the hand. Treatment of the phlegmon of the hypotenar region. A linear arcuate incision is made along the inner edge of the elevation of the muscles of the hypotenar. The dorsal contourperture incision corresponds to the outer margin of the V metacarpal bone. Having completed the main manipulations in the purulent focus, the wounds are connected together. Drainage is carried out by two tubes, one of which is carried out along the inner edge of the fascial bed of the hypotenar, and the second - along the main incision.

Treatment of phlegmon in the naponeoneurotic region

The following accesses are optimal:

• an arcuate Bunnel incision from the second interdigital palm spacing at the level of the distal lateral fold parallel and medial to the fold of the tenar to the distal boundary of the wrist area (a fragment of this access may be used);
• arcuate incisions parallel to the distal or proximal transverse palmar grooves (according to Zoltan).

Confirmation of the nidoneurotic localization of the focus makes it unnecessary to cut the palmar aponeurosis with the removal of through drains through the counter-aperture cuts at the rear of the hand. The stage of necrectomy and sanation of the focus is carried out in accordance with the established procedures, after which two perforated micro irrigators are installed Y or T-shaped.

Treatment phlegmon median palmar space

For the opening of phlegmons of the median palmar space, the modified access of Zoltan should be considered the method of choice. The incision starts 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 arcately proximally along the fold of the tenar to the "forbidden zone". Mobilization of the formed flap along with fiber (to preserve its blood supply) provides access to virtually all cellular spaces of the palmar surface of the hand, which creates conditions for full and broad necrectomy.

If there is a significant incision in the area of the basement (after primary trauma or operations in other medical institutions), the risk of ischemia and subsequent necrosis of the flap is extremely increased. In these cases, it is advisable to make a cut similar to that described above, but as if mirrored with respect to the longitudinal axis of the brush.

With significant damage to the skin in the central part of the palm, the execution of any of these incisions is undesirable. 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 muscle retainer.

Regardless of the choice of access, the dissection of the palmar aponeurosis is carried out in the longitudinal direction and the necrectomy is performed as it moves deeper into the tissues. Revision of flexor tendons themselves and sub-tidal (deep) space is necessary for assessing their condition and identifying possible purulent feces.

After necrectomy, drainage is performed. Usually there are three or four micro-irrigators enough: two or three tubes (depending on the prevalence of the process) are placed under the palmar aponeurosis, then under the lateral ligament of the palm and removed through additional punctures at the level of the distal fold of the area of the wrist joint and in two or three drainage) interdigital intervals. Another micro-irrigator is carried out under the tendons of the flexors in the transverse direction and is withdrawn through additional punctures. After the installation of drains, the integrity of the palmar aponeurosis is restored (atraumatic sutures 3/0-4 / 0).

Contrary to the often mentioned technique of performing contour-percutaneous incisions at the rear of the hand and through the palmar-back drainage in this pathology, there is no basis for such completion of the operation if there are no grounds for brushing on the rear of the hand (through the interstipar spaces).

Treatment of phlegmon of the rear of the hand

Autopsy of the phlegmon of the rear of the hand is carried out by several arcuate small (up to 3.0 cm) incisions along the Langer line along the perimeter of the purulent cavity. Entrance gates are subject to surgical treatment and can be used as one of the accesses.

For draining the formed cavity along the lateral and medial edges, two micro-irrigators are inserted in the longitudinal direction, which are withdrawn through additional punctures. It should be emphasized that the primary seams are shown only with full confidence in the viability of the tissues of the rear of the hand. With skin defects after necrectomy or with obvious ischemia of the skin of the rear of the hand, it is preferable to loose the wounds with gauze strips with ointment on a water-soluble basis.

Treatment of the phlegmon of the hand and the space of Pirogov-Parony

Operative intervention with a U-shaped phlegmon begins with one-sided longitudinal lateral incisions along the "non-working" surfaces of the middle phalanx V of the finger and the main phalanx of the 1st finger, from which the corresponding tendon sheaths are opened. Longitudinal side incisions in the lower third of the forearm reveal the Pirogov-Parona space. With the fishing line guide of a set-catheterization subclavian vein through the lumen of the tendon sheath uncovered I and V fingers proximally perforated mikroirrigatory performed with an internal diameter of 1.0 mm and their ends are mounted in Pirogov-cellular spaces Paronit.

The next stage of the operation is the execution of incisions in the area of tenar and hypotenar, similar to those for isolated phlegmon of these cell spaces. At the same time, it is possible to audit the flexor tendons of the first and fifth fingers and their vagina almost throughout the entire length.

After washing the vagina with an antiseptic solution, necrectomy in all wounds, evacuation and ultrasound sanation, each of the cell spaces involved in the purulent process (tenar, hypotenar and Pirogov-Paronas) are drained with polyvinyl chloride drainage tubes perforated in the middle.

Treatment of phlegmon of a brush of a combined character

The modified access of Zoltan is considered optimal for opening several cell spaces on the palm surface of the hand. When the median palmar space and the area of the tenar are affected, the incision is performed in parallel or along the distal dermal fold of the palm with an arcuate extension along the border of the tenar into the proximal parts of the wrist to the level of the wrist. When the median palmar space and the hypotenar region are affected, similar access is used, but turned around the longitudinal axis of the palm by 180 °. Simultaneous defeat of the purulent process with one or more interdigital spaces does not require additional incisions and does not influence the choice of proposed access, since any of them provides sufficient exposure for revision of interdigital cell spaces. Moreover, after mobilization of the skin-hypodermic flaps from these accesses, revision and performance of necrectomy on the larger part of the palm are possible. The existing purulent fuzz on the back of the hand is opened with several arcuate incisions in accordance with the Langer lines.

Implementation of these accesses is contraindicated in case of significant wound defects in the zone of the middle palmar space because of the risk of developing necrosis of the mobilized skin-subcutaneous flap. In these cases, a T-shaped incision is preferred, the transverse part of which is performed parallel to or along the distal fold of the palm, and the longitudinal one from its center in an arcuate manner through the existing wound to the level of the wrist. This access due to its longitudinal part is less physiological than 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.

When you involve in the purulent process of the Pirogov-Parona space, any of the above accesses should be continued to the level of the distal cutaneous fold of the wrist joint region, then - along the crease to the radial edge of the lower third of the forearm, and complete with a longitudinal incision to dissect the phlegmon of the pirogov space.

With phlegmons of the brush with the spread of pus on the fiber of the forearm above the square pronator, arcuate access to the canal is preferred, continued on the forearm.

Necrectomy, especially in neglected cases, must be performed in violation of topographic relationships and the anatomical integrity of the structural elements of the brush, and it requires considerably more time and patience than the surgical treatment of any of the isolated phlegmon.

To adequately drain the postoperative residual cavities on the palms, two or three perforated tubes usually run along the edges of the corresponding cell spaces. The interdigital spaces involved and the rear of the hand are always drained separately.

With confidence in the radicality of the performed necrectomy, primary seams are applied to the skin. Remained in the wounds of tissue diffusely impregnated with pus (such as honeycombs), skin areas of dubious viability are considered a contraindication to suturing wounds. In these cases, it is preferable to loosely perform their gauze strips, richly impregnated with ointment on a water-soluble basis.

The purulent process on the wrist is most severe with simultaneous damage to all cellular spaces (total phlegmon). The accesses described above are used. Nevertheless, one of the peculiarities of their course is a rather rapid development of skin necrosis at the rear of the hand, which is diagnosed already when patients enter 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 the surgical treatment of total phlegmon (due to the vastness of the lesion, diffuse purulent fibrous imbibition in the absence of clear boundaries of necrosis and an unfavorable therapeutic background) lies in the fact that it is practically impossible to radically perform a necrectomy at the time of the first operation. This determines the completion of the surgical intervention - never be imposed on the wounds of the primary sutures. All cellular spaces are subject to loose plugging with gauze strips impregnated with ointment on a water-soluble basis. In the following days, such patients are shown daily stage necrectomies under anesthesia in the operating room. This tactic completely justifies itself and usually by 10-14 days it is possible to stop acute inflammation and begin closing of wounds by imposing early secondary sutures or skin plasty.

Treatment of phlegmon brushes combined nature

Operative accesses with combined phlegmons of the hand should ensure the revision of not only the finger structures, but also the brush spaces involved in the process, without violating the integrity of the neurovascular bundles and minimizing the possible functional damage. That is why with combined phlegmon of the brush, two options of access are used, regardless of the type of panaritium. When the process is localized on the back surfaces of the fingers and the hand, a cut is made along the lateral neutral line of the affected finger with an arcuate transition to the rear of the hand. When defeat the palmar surface of the finger and hand feel optimal incision on the side of the neutral line concerned thumb, but with an arcuate transition region corresponding to paltseladonnogo elevation, and the affected cellular spaces on palm expose S-shaped extension of the existing palmar incision in the proximal direction. Purulent fuzzes on the back of the hand are opened with arcuate incisions along the lines of Langer. The existing purulent wounds (the entrance gates or after the previous operations) are economically excised by Kosh, possibly involving in the main access.

The principles of performing necrectomy have been highlighted in the treatment of deep forms of panaritium and isolated phlegmon. Having completed the sanation of the hearth, all the involved anatomical formations and cell spaces drain into the inflammatory process by thin perforated polychlorvinyl tubules. The principle of superimposing the drainage-washing system remains the same: the minimum amount of drainage should ensure the drainage of residual cavities on both fingers and hands. Synovial bags and tendon sheaths should be drained separately if they are intact. In cases of destruction of the vagina or synovial bag, one or two drains in the subcutaneous tissue laid along the "bare" tendons. Also, separate drainage is required for the joint cavity after the intervention for arthritis or osteoarthritis, and in the interphalangeal joints, the micro-irrigators are installed transversely, and in the metacarpal phalanges - sagittally.

With combined phlegmon with defeat of purulent process of joints, management of the postoperative period in the mode of distraction is extremely important. Since the imposition of the distraction apparatus in conditions of phlegmonous inflammation of soft tissues is impossible, it is optimal to use for this purpose a spinal design or a device for the distraction of the metacarpophalangeal joints.

If it is impossible to impose primary sutures on all wounds, it is advisable to impose them on individual defects that are clearly viable. In the future, small open wounds (up to 1.5 cm in length and up to 0.5 cm in width) are quickly healed by secondary tension. Wounds of large sizes (up to 1.5 cm in width) are superposed with early secondary seams. At extensive wound defects after a cupping of an inflammation various variants of a dermal plasty are applied.

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

The purulent process on the fingers and hands proceeds most maliciously against the background of diseases accompanied by severe 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.