FELON (Latin. panaricium) — the acute inflammation of tissues of finger resulting usually from infection of its small damages. The inflammatory processes complicating extensive wounds of fingers do not belong to P. V these cases speak about contaminated wounds of fingers.
For practical work of surgeons is most reasonable P.'s classification based on the accounting of anatomic localization of inflammatory process (fig. 1). On this classification distinguish the following types of P.: skin, periungual (paronychia), hyponychial, hypodermic, bone, joint, tendinous, pandactylitis.
More often P. are ill the persons performing the work tied with a possibility of traumatizing hands, pollution by their lubricants irritating skin with substances (general workers, loaders, mechanics, tractor operators, workers of the weaver's industry, etc.). At 80% of the diseased P. of nail phalanxes I, II or III fingers of the right brush is observed.
The etiology and a pathogeny
the Most widespread activator P. is white or golden hemolitic staphylococcus in a monoculture or in association with other microbes. Less often the inflammation is caused by colibacillus, Proteus, a streptococcus, etc. Sometimes as a cause of illness serves the putrefactive, and also fungal infection.
Microbes get into fabrics from the environment or surface layers of skin of a finger at small, especially not debrided damages (grazes, wounds given by sharp objects — needles, metal shavings, wooden splinters, etc.); extremely seldom infection happens in the hematogenous way.
P.'s emergence is promoted decrease immunol, reactivity of an organism, exhaustion, disbolism, endocrine diseases, and also long impact on skin of hands of the irritating substances, cold, moisture, vibration, at to-rykh come disorders of microcirculation and a trophicity of fabrics, protective function of skin is broken. It is experimentally proved that many chemical substances and metals (copper, tsknk, cobalt, chrome, etc.), getting to a wound, have toxic effect on fabrics and also promote emergence of the Item.
Further development and features of a current of P. unlike purulent diseases of other localizations considerably are defined by features of an anatomic structure of a finger: abundance on a small extent of functionally important educations (the fibrous vaginas, sinews, synovial vaginas, vessels, elements forming joints), a yacheistost of an arrangement of the hypodermic cellulose penetrated by fibrous crossing points. All these factors promote penetration of an infection deep into and to its transition to sinews and the bone and joint device. The phase of serous treatment of fabrics usually short, quickly is replaced by a phase is purulent - a necrotic inflammation since accumulation of exudate in the closed spaces brings into short terms to disturbance of blood circulation, a necrosis of fabrics, their purulent fusion.
The clinical picture
the Constant sign of all forms P. is the severe pain of the pulsing character more sharply expressed in the center of a suppurative focus and at its localization on the palmar surface of a finger where fabrics are tenacious and plentifully supplied with nerve terminations. Pain amplifies at the movements of the finger which is usually in halfbent situation. As a rule, there are swelling and puffiness of a finger, a dermahemia which are most accurately defined on its back surface, local temperature increase expressed in a different measure. The general disturbances in an organism of patients are expressed less, than local. In a stage of suppuration pain becomes painful, leads to sleeplessness; the bright redness is noted more on the periphery of the center, than in the center; body temperature is increased (with remissions); increase and morbidity regional limf, nodes are defined.
At skin P. the suppurative focus is located in the thickness of skin (fig. 1, 1) under epidermis. The impetigiozny bubble with serous, purulent or hemorrhagic contents is formed, to-ry can be located both on palmar, and on a dorsum of any of phalanxes, sometimes occupying almost all surface of a finger. The bubble is surrounded with the narrow inflammatory roller. Pain in the beginning insignificant, but in process of accumulation of pus amplifies, becomes the constant pulsing. Sometimes the center of a hyperemia around a bubble extends, joins limfangiit (see) and regional lymphadenitis (see), followed by fervescence to high figures. Earlier similar defeat was called a lymphatic felon. In modern surgical literature this term is practically not used. At skin P. the suppurative focus in the thickness of skin can be reported with the center in hypodermic cellulose — a so-called felon in the form of a cuff link (fig. 1, 8).
At periungual P. — paronychias (see) a purulent inflammation it is localized in the thickness of the roller of a nail: in its side site, over a root of a nail, or throughout the roller (fig. 1, 2). Skin of the roller reddens, swells up a little (tsvetn. fig. 1), from under the roller during the pressing appear drops of pus.
Hyponychial P. is characterized by accumulation of pus under a body of the nail (fig. 1,3). It arises at infection of the chipped wounds getting under a nail, suppuration of hyponychial hematomas or as a complication of a paronychia; proceeds sharply. The nail is raised, through it illuminates pus. Restriction of a suppurative focus with a dense nail plate causes the constant sharply expressed throbbing pain.
Hypodermic P. — an inflammation of hypodermic cellulose of a finger (fig. 1, 4) — the most common form of P. Chashche meets hypodermic P. of the palmar surface of distal phalanxes. As on a dorsum of fingers skin mobile, and hypodermic cellulose friable also contains much limf, the vessels which are widely anastomosing with limf, vessels of a palmar surface, at an arrangement of a suppurative focus on the palmar surface of a finger hypostasis, a swelling and a dermahemia are more accurately expressed on side surfaces and the back of a finger. The finger (or a phalanx) increases in volume, becomes intense (tsvetn. fig. 2, 3). Big thickness, density and inflexibility of skin of a palmar surface, cellular arrangement of hypodermic cellulose promote bystry distribution of inflammatory process towards a periosteum and sinews. Pain is constant, amplifies at extension and weakens at moderate bending of a finger. The point of the greatest morbidity corresponds to localization of the center of a suppurative focus. Often the patient loses a dream because of pain, is exhausted, body temperature increases to 38 — 39 °. The bone, sinews, joints (fig. 2) can be involved in a purulent inflammation. From the center which is localized in a proximal phalanx of a finger, purulent process can pass on friable cellulose of interdigital intervals into canals of worm-shaped muscles, distal department of a palm and to proximal phalanxes of the next fingers (fig. 3).
Bone P. is called the purulent inflammation of a finger with involvement in process of a bone tissue (fig. 1, 5). Distinguish bone P. of distal, average and proximal phalanxes. Bone P. can be primary, resulting from deep chipped wounds and a drift of an infection in a bone hurting subject. This form meets seldom. The secondary bone Felon, the reason to-rogo — transition of an inflammation from soft tissues to a bone prevails. The necrosis and purulent fusion cause emergence of defect of a bone or formation of sequesters. The wedge, bone P.'s picture in an early stage does not differ from that at hypodermic in P. Vskore all symptoms become sharply expressed. At damage of a distal phalanx the finger gets a kolboobrazny form with intense, brilliant, smooth skin. Pain has constant character. There is a fever, a headache, temperature increases to 39 ° above. Sinews, joints can be involved in purulent process.
Joint P. is characterized by a purulent inflammation of interphalangeal or metacarpophalangeal joints (fig. 1, 6). Distinguish two stages of a current of joint P. V of the I stage only soft tissues of a joint are involved in process: there is a dermahemia, hypostasis, a smoothness of interphalanx folds; the finger gets a spindle-shaped form. Tolchkoobrazny pressure on a longitudinal axis of a finger sharply strengthens constant pain. At a puncture of a joint (see. Joints ) it is possible to receive muddy liquid. In the II stage joint cartilages, side sheaves collapse, there comes destruction of the bones forming a joint. Arises patol, mobility, up to an incomplete dislocation in a joint, crepitation of joint surfaces is defined. There can be a spontaneous opening of tagy P., at the same time fistula with granulations and purulent separated is formed.
Tendinous P. — a purulent inflammation of a vagina of a sinew and sinew of a finger (fig. 1, 7). The inflammation of sinews of razgibatel of fingers, as a rule, does not happen. Sinews of sgibatel of fingers are usually involved in process for the second time, the inflammation passes to them from a vagina of sinews. The prelum of the thin vessels suitable to a sinew through mezotendiniya, the exudate which is quickly collecting in a vagina of a sinew and fibrinferments them is brought into short terms to a necrosis of a sinew. Pus from a vagina can break outside with burrowing (fig. 4). At a thecal whitlow of the I finger pus can spread on a vagina of a sinew of a long sgibatel of a thumb of a brush in the general synovial vagina of sgibatel and to the V finger. There is a so-called cross felon. Distribution of purulent process and in the opposite direction — from the V finger to I is possible. Process can sometimes pass to deep layers of a forearm — into so-called space of Pirogov — Parona. It is not observed at a thecal whitlow II, III and IV fingers, vaginas of sinews to-rykh are isolated from the general synovial vagina of a sgibately brush. The main sign of tendinous P. — the constant pain on the course of a sinew amplifying in attempt of extension of a finger. Untimely surgical intervention involves a necrosis of a sinew on a big extent, rejection to-rogo happens very slowly. The impractical sinew looks gray, dim. Flexion function of a finger drops out.
Pandactylitis (grech, pan all + daktylos a finger + - itis) — the progressing purulent inflammation of all tissues of finger, including sheaves, sinews, bones and joints. Results from a complication or the wrong treatment of easier forms P. The finger sharply is deformed, increases in volume, skin gets a crimson and cyanochroic shade, is strained, shines. There are fistulas, from to-rykh pus is emitted, sites of a nekrotizirovanny fatty tissue, sinews, bone sequesters are torn away; mobility and crepitation in interphalangeal joints is quite often observed patol.
Complications arise owing to untimely or wrong treatment of initial forms P more often. At the same time process can consistently pass from one department of a finger to another, as well as out of its limits, causing developing of deep phlegmon of a forearm, phlegmon of a brush (see. Brush ), purulent inflammation of a radiocarpal joint, etc. The necrosis and scarring of fabrics, especially in joints and vaginas of sinews, and also a long irrational immobilization of a brush can result in rigidity, a contracture and an anchylosis of joints of a finger and a brush.
The diagnosis is based on the characteristic anamnesis, a wedge, and rentgenol, a picture. It is necessary to define precisely localization it is purulent - the necrotic center, to establish a phase of inflammatory process and a wedge, a form of a disease. During the collecting the anamnesis it is important to specify whether there were in the next past small injuries of fingers, whether processing was carried out them, whether the factors promoting developing of purulent diseases take place (impurity of hands, etc.); what prescription of a disease whether there were sleepless nights because of pains; what is carried out treatment. At a careful research of a finger determine the place of the greatest morbidity by the bellied probe (according to the old practical rule «the finger a finger is not palpated»), a cut usually corresponds to localization of a suppurative focus (fig. 5).
P.'s radiodiagnosis is made by method of a X-ray analysis in two mutually perpendicular projections. Are preferable a screenless X-ray analysis soft radiation, a X-ray analysis with direct blowup, electrox-ray analysis (see). At P. of soft tissues of a finger rentgenol, images of bone phalanxes are normal and only at very long current of P. the adjacent phalanx can undergo to osteoporosis (see).
At a bone felon already by the end of the 1st week of a disease on roentgenograms the uneven enlightenment — reactive osteoporosis of the struck part of a phalanx is noted up to almost total disappearance of structure of this part of a phalanx at further development of P. (fig. 6, a). On a zatikhaniya of an inflammation of an outline and structure of a phalanx are recovered in 3 — 5 weeks. Wrong interpretation of this enlightenment of a phalanx as necrosis can lead to an unjustified resection or even an exarticulation of a viable phalanx. Unlike the described picture the nekrotizirovan-ny part of a phalanx deprived of blood supply keeps a shadow of normal intensity on roentgenograms; the formed sequester often is displaced (fig. 6, b). At an intaktnost of an adjacent joint the joint crack and subcartilaginous bast layers remain. At bone P.'s complication purulent arthritis on roentgenograms in addition to osteoporosis observes the progressing narrowing of a joint cavity (owing to a chondrolysis of joint cartilages), roughness and an illegibility of contours of the joint ends (fig. 7, a). Purulent arthritis can sometimes be complicated by distenzionny dislocation or an incomplete dislocation of a phalanx (fig. 7, b).
Joint P. conducts to an anchylosis; at the same time on the roentgenogram bast layers of the joint ends and a joint cavity, on site a cut disappear the bone and trabecular structure passes from one bone into another. At it is active and long the current bone or joint P. the enlightenment of all adjacent bones of a brush can be observed (hl. obr. joint ends of bones), i.e. regional osteoporosis. At bone P. of a distal phalanx on roentgenograms there is no ossifying periostitis owing to small activity of a cambial, osteogene layer of a periosteum here.
Damage of fingers is possible at tuberculosis, an actinomycosis, a tularemia, etc. Specification of the diagnosis in such cases sometimes presents the known difficulties and demands the special bacteriological and serological researches conducted at the corresponding diseases (see. Actinomycosis , Gonorrhoea , Syphilis , Tularemia etc.).
the Main method of treatment of P. — operational. Conservative therapy can be effective only in an initial (serous and infiltrative) stage. However the complex of conservative actions plays an important role as addition to operation. At the same time providing rest to the affected finger and all brush is of great importance, to-ry it is reached by imposing of a plaster splint on a brush and a forearm in functionally advantageous position (see. Plaster equipment ). Apply hot bathtubs to a brush and a distal part of a forearm, UVCh-therapy, an electrophoresis with trypsin and other enzymes, diadynamic currents, ultrasound, a roentgenotherapy, sometimes resort to a local hypothermia. After subsiding of the acute phenomena after operation apply a set of exercises of LFK. Especially essential component of complex treatment of P. is antibacterial therapy, as a powerful tool a cut serve antibiotics of the directed action. They can be entered locally as short blockade (see. Novocainic blockade ) or in soft tissues of a proximal phalanx of a finger, and also vnutrikostno, intramusculary (according to the accepted scheme), intravenously and vnut-riarterialno. Local introduction of antibiotics though provides high concentration them in the center of an inflammation, however is painfully and hard transferred by patients. Intra bone introduction is especially reasonable at bone P. Vnutrivennoye (in saphenas of front elbow area) introduction is simpler intra arterial (in a humeral artery) and therefore it is applied more often. In P.'s treatment
the method of an immunotherapy is widely adopted (staphylococcal anatoxin according to the scheme, antistaphylococcal gamma-globulin, hyperimmune anti-staphylococcal plasma, a bacteriophage, etc.); also enzymotherapy is applied (trypsin, chymotrypsin, etc.).
In a stage it is purulent - a necrotic inflammation (not later than the first sleepless night) operation is necessary, at a cut carry out broad opening of a suppurative focus, radical excision of nekrotizirovanny fabrics (see. Necretomy ) and rational drainage (see). Operation is made usually under a local anesthesia across Lukashevich — to Oberst (see. Anesthesia local ) with imposing on the basis of a finger of a thin rubber plait for the purpose of a hemostasis (fig. 8). At P. of a pooksimalny phalanx or transition of inflammatory process to a brush resort to intravenous or intradermal anesthesia, and is more often to the general to anesthesia (see).
Apply rubber (fig. 9) or chlorvinyl tubes, rubber strips, filar drainages to drainage of a suppurative focus, etc. After operation apply a gauze bandage with antiseptic agents a wound (Furacilin, furagin or other), rest is provided with imposing of a plaster splint.
Radical excision of nekrotizirovanny fabrics, topical administration of antibiotics, and also proteolytic enzymes allows to impose in nek-ry cases of hypodermic or bone P. primary delayed (see. Primary seam ) or early secondary seams (see) that promotes considerable reduction of terms of disability of patients.
At skin P. the exfoliated epidermis is pierced with sharp-pointed scissors and carefully exsected; at the same time anesthesia usually is not required. Apply a bandage with solution of an antiseptic agent a wound surface (penicillin, Furacilin or other). For prevention of a recurrence the wound is irradiated with UV rays. At P. in the form of a cuff link carry out operation, as at the hypodermic Item.
Hyponychial P.'s treatment only operational. At an arrangement of pus near free edge of a body of the nail the nail plate is excised under local anesthesia in the form of a wedge. Often in such cases the foreign body is found — the splinter which was P. Polnostyyu' reason delete a nail (fig. 10) only at amotio with its pus on a big extent.
At hypodermic P. only in the most initial (serous and infiltrative) stage conservative treatment can be tried, opportunities to-rogo should not be revaluated. In the absence of the next effect of the carried-out conservative therapy, and also at a sformirovaniye of the center of a purulent inflammation operation is shown. Character of a section is defined by localization of a suppurative focus. On a distal phalanx do oval or semi-oval (klyushkoobrazny) cuts (fig. 11). The oval section allows to examine all departments of a phalanx, to considerably excise nekrotizirovanny fabrics, provides good outflow of pus therefore it is applied in cases of a heavy current of the Item. At this access sensitivity of a finger-tip remains. The section is carried out not further 2 — 3 mm from free edge of a nail that the doubled finger (a so-called fish mouth) was not formed afterwards. For the purpose of prevention of the doubled finger resort to extension of a palmar rag of a phalanx an adhesive plaster or to imposing of the directing seams (see. Seams surgical ). Apply a semi-oval section more often, later to-rogo the doubled finger it is not formed. Hypodermic P. of average and proximal phalanxes is opened with two palmar and side cuts which are carried out through all length of a phalanx.
Bone P.'s treatment consists at a distance is purulent - necrotic substrate of soft tissues and an impractical bone, intervention on a cut shall be radical and economical. Especially carefully it is necessary to treat a proximal metaepiphysis of a distal phalanx, for the account to-rogo there is a regeneration of a bone. The Nekrotizirovanny site of a bone is excised acute nippers or carefully scraped out an acute bone spoon.
Joint P.'s treatment in an early stage consists in a puncture of a joint, introduction in it of antibiotics, use of all complex of conservative therapy. In the absence of effect after 3 — 4 punctures do operation (see. Arthrotomy ). Open with two back and side cuts a joint, wash out it solution of an antibiotic, delete impractical fabrics. At destruction of cartilages and a bone make their economical resection.
In an initial stage of tendinous P. methods of conservative treatment with punctures of a vagina of a sinew can be applied to evacuation of exudate and introduction of antibiotics. At inefficiency of conservative treatment operation is shown. For opening of a vagina of a sinew many cuts (fig. 12) are offered, however it is necessary to apply discontinuous unilateral or pair linearly - side cuts on average and proximal phalanxes. It is reasonable to open a cul-de-sac of proximal department of a vagina with two cuts on a palm at the basis of a finger. Cuts on the centerline of a finger since they, as well as the cuts practicing earlier throughout a sinew which are carried out sideways (cuts Bira and Kanavela), lead to heavy changes of a sinew and loss of function of a finger are inadmissible. The vagina of a sinew is drained a rubber strip for no more than 2 days.
At a pandactylitis in most cases it is necessary to resort to an exarticulation of a finger in a metacarpophalangeal joint with removal of a head of a metacarpal bone (see. Exarticulation ). Sometimes a rational operative measure with the subsequent antibacterial therapy allows to keep a finger. At the solution of a question of the nature of operation on the I finger it is necessary to consider that even at full loss of mobility it keeps funkts, suitability due to the movements of a metacarpal bone.
Early radical operation provides bystry recovery with good funkts, results. At severe forms of the Felon (tendinous, joint, etc.) and their complications the forecast concerning recovery of function can be adverse.
Prevention consists in respect for personal hygiene, the prevention of small injuries of fingers; are important increase a dignity. cultures of the population, improvement of the accident prevention and improvement of working conditions (supply with overalls, e.g. gloves, mittens, etc., mechanization, automation of productions, etc.). Decrease in incidence of P. is promoted by processing of microtraumas of 0,5% solution of spirit of ammonia, 5% spirit solution of iodine, film-forming antiseptic liquids like «furolayer», etc.
Bibliography: Grigoryan A. V., of an awn-shchev of V. K. of ikostik of B. A. Purulent diseases of a brush, page 78, M., 1978; To oyk about A. A., etc. Use of a roentgenotherapy in complex treatment of a felon, Klin, hir., No. 1, page 38, 1979; Lishke A. A. and JI at N of e of about in A. I. A bone felon at adults and children, Perm, 1977; Lytkin M. I. and Braids and-chev I. D. Panaritsy, L., 1975; Meleshe-v and p A. B. Use of a gauze, silk • and kapron threads at treatment of contaminated wounds of a brush, Surgery, No. 12, page 96, 1978; P about p to and r about in S. Gnoyno - septic surgery, the lane with bolg., page 348, ¦ Sofia, 1977; Reynberg S.A. Radiodiagnosis of diseases of bones and joints, book 1, page 305, M., 1964; V. I Pods. Purulent surgery, page 156, etc., M., 1967; M i with h on J. Le panaris, Ann. Chir., t. 28, p. 255, 1974; N i with h o 1 1 s R. J. Initial choice of antibiotic treatment for pyogenic hand infections, Lancet, v. 1, p. 225, 1973; R e i 1 1 P. Infektionen der Hand, Diagnose, Therapie und Komplikationen, Ther. Umsch., Bd 32, S. 778, 1975; 5 with h i n k W. Pyogene Infektionen der Hand, Chirurg, Bd 42, S. 356, 1971.
AA. B. Lutsevich; S. I. Finkelynteyn (rents.).