Purulent diseases of a hand
It is accepted to name a purulent inflammation of tissues of dactyls a panaritium (раnаricium). Acute purulent diseases of a hand and dactyls in out-patient surgical practice frequency of panaritiums and phlegmons occupy one of leading places fluctuates from 15 - 18 to 20 - 30 % among patients of surgical offices of out-patient departments. Among the diseases causing depression of working capacity at workers of physical work, 8 - 10 % are caused by pyoinflammatory diseases of dactyls and hands. Being a consequence of the insignificant (latent) microtrauma, panaritiums and hand phlegmons lead to disability that the injury causes to health and demands the big material inputs on treatment.
Aetiology and pathogenesis
The panaritium originator in most cases is the staphilococcus, is rarer - other originators. As entrance infection atriums fine damages of a hand (nyxes, grazes serve, to an attrition). Introduction of an infection contamination and inflammation development are promoted by foreign bodys - splinters, fine splinters of glass, a metal shaving. In a place of introduction of an infection contamination round foreign bodys the edema, inflammatory infiltration of tissues with the subsequent purulent infiltration educe. The formed pus owing to features of a constitution of a fat (erect position of strong connective tissue bands) breaks outside or extends deep into on a subject tendon, a joint, a bone, leading to development of a tendinous, articulate panaritium. Probably primary development of inflammatory process in a tendon heath or in a joint at their inpouring damages and a becoming infected. Inflammatory process passes usual stages of the development, and its diffusion is defined by features of an anatomical constitution of a hand.
In serious cases all tissues of a dactyl can be involved in inflammatory process (pandactylitis). The prelum of tissues at inflammation development promotes formation of so-called dry necrosises at panaritiums, thus in due time and correctly executed operation is preventive maintenance of advance of inflammatory process.
Features of an anatomical constitution of a hand
The complex anatomical constitution of a hand, its thin and diverse function have caused also the specificity of a skin considerably differing on the constitution from other integument of the human. The skin of a dorsum of a hand elastic, mobile, easily is stretched and collects in cords. The hypodermic fat is educed weakly and consists basically of a quaggy copulative tissue. The palm skin is dense, inactive because of adnations with a palmar sheath, is deprived hair bulbuses and sebaceous glands. The hypodermic fat of a palm consists between the plural erect connective tissue fibers binding a skin with sheaths. Therefore the fatty tissue appears concluded in separate alveoles and is presented in the form of separate fatty lobes.
The connective tissue fibers binding a skin with a sheath and parting a fatty tissue on alveoles, at hand wound are conductors of an infection contamination from a surface in depth, preventing at the same time diffusion of inflammatory process to width. Therefore pyoinflammatory processes of a hand and dactyls are dangerous fast transition at out of time begun treatment) on tendinous and an ossa.
In the field of a palmar surface of a hand distinguish superficial and deep fascias. The superficial fascia passes immediately under a skin and its fatty tissue. The palmar sheath is formed of tendinous fibers, has the triangular form, a dense consistence, connective tissue bands depart from radial and ulnar its edges to III and to V metacarpal bones. These bands divide a palm into three parts: range thenar, a hypothenar and median palmar space which through commissural foramens (cleft) intercommunicates with a back of the hand. On these clefts inflammatory processes from a palm can extend on a hand dorsum. The deep palmar fascia passes under tendons of flexors of dactyls and together with muscles forms a bottom of a hand. Between a deep fascia, interosseous muscles and tendons of flexors there is a deep spatium cellulysin space of a hand. The purulent exsudate from here through the carpal canal can extend on a forearm in spatium cellulysin space. In a distal direction pus from median palmar space at unfavorable conditions inpours through canals of worm-shaped muscles on a dorsum II - V dactyls and into the second - the fourth interdigital interspaces. The carpal canal is a link between a palmar surface of a hand and a forearm.
Through the carpal canal on a palmar surface of a hand pass a median nerve and tendons of flexors of dactyls. Through deep spatium cellulysin space of a hand there passes a deep arterial palmar arch. In superficial spatium cellulysin space there pass a superficial palmar arch, arteries of dactyls and a median nerve. On a palmar surface of a hand distinguish still outside and intrinsic fascial beds. In the intrinsic bed located between own fascia and a forward surface of V metacarpal bone, together with a fascial septum there are hypothenar muscles, and also deep branches of a radial artery and a nerve. The outside fascial bed which contents is the thenar, from the inside adjoins on a place of affixion of own fascia to III metacarpal bone, with outside - with a lateral surface of I metacarpal bone.
Distinguish synovial vaginas of tendons of muscles of a back and palmar surface of a hand. In the field of a palmar surface the general vagina of flexors, a tendon sheath of a long flexor of a dactyl of a hand, a vagina of tendons II-IV of dactyls of a hand settle down. First two vaginas fill the wrist canal. The radial tendon heath of a long flexor of I dactyl begins on 2-3 sm more proximally an awl-shaped process of a radial bone and comes to an end at a place at fastening of a tendon of a long flexor to the establishment of a nail phalanx of a dactyl. The ulnar vagina contains tendons of flexors II-V of dactyls, it is much wider than a radial synovial bed. More proximally metacarpal - phalanx articulations the synovial vagina forms the pouch, then is narrowed and proceeds to the establishment of a nail phalanx only V dactyl.
Palmar synovial vaginas of tendons II-IV of dactyls are isolated from each other. They begin at level of metacarpophalangeal articulations and proceed to the establishment of nail phalanxes.
Synovial vaginas of tendons of a hand have certain value and a pathogenesis of inflammatory process. The inflammatory exsudate which has collected between parietal and visceral leaves, can cause destruction of a tendon owing to a prelum of its mesenteriolum and the pots passing in it providing a food of a tendon. In such cases only timely dissecting of a tendinous vagina can prevent ги6ель pots feeding a tendon and by that to salvage a tendon and to keep high-grade function of a hand or dactyls.
Classification
- Purulent diseases of dactyls:
- A dermal panaritium
- A hypodermic panaritium
- A thecal whitlow (thecal abscess)
- Articulate a panaritium
- An osteal panaritium
- A paronychia
- A hyponychial panaritium
- A pandactylitis
- A furuncle (anthrax) of back of a dactyl
- Purulent diseases of a hand:
- An intermuscular phlegmon of a thenar
- An intermuscular phlegmon of a hypothenar
- A commissural phlegmon
- A phlegmon of median palmar space (over - and subtendinous, over - and subaponeurotic)
- A two-dimensional (U-shaped) phlegmon
- Hypodermic (overaponeurotic) a phlegmon of a back of the hand
- subaponeurotic a phlegmon of a back of the hand
- A furuncle (anthrax) of a back of the hand
Excrete initial (serously - infiltrative) and purulent (it is purulent - necrotic) inflammation stages.
Clinical picture of purulent diseases of a hand
The clinical picture of purulent diseases of a hand, as well as any other inflammatory process, develops of known general and aboriginal signs: an edema, a hyperemia, a pain, a fervescence and disturbance of function of an organ. However inflammatory processes of dactyls and a hand have specific characters.
At an inflammation of a hypodermic fat of a forearm, a shoulder or an anticnemion aboriginal signs of an inflammation are localised immediately in region the most expressed destructive changes. At an inflammation, a hypodermic fat of a palmar surface of a hand morbidity and some smoothness of contours of a palm only are palpatory defined. Other signs of an inflammation (a hyperemia, sharply expressed edema) are most expressed on a hand dorsum. Last circumstance then complicates definition of localisation of a suppurative focus and serves as the cause of diagnostic mistakes. Thereof is irregular made cuts not only extend invalidity terms, but also are rather essential reflected in the nearest and remote (functional) outcomes of treatment. Therefore it is the extremely important, considering features of an anatomical constitution of a hand and dactyls to choose a correct place for suppurative focus dissecting, to remove pus and to prevent the further prelum of tissues an inflammatory exsudate.
The hypodermic panaritium concerns. To most often meeting kinds of a purulent inflammation of a hand. In most cases it is necessary to meet purulent forms of disease of dactyls as patients during the first hours and days of disease was rarely address to doctors. For a hypodermic panaritium morbidity in a place of occurrence of inflammatory locus is characteristic. The pain wears gradually accruing, pulling, pulsing character. During the first hours, and sometimes even patients, as a rule, continue to carry out days of disease usual ра6оту. However the pain gradually accrues and deprives of sick rest and a sleep.
At dactyl research attract attention a strain of tissues, sometimes a smoothness located near to the inflammatory locus interphalanx incurvate sulcuses. The hyperemia of integuments is expressed not sharply, At a methodical and consecutive palpation by means of a bellied probe it is easy to define region the greatest morbidity which corresponds to a suppurative focus locating.
State of health of the patient bad because of a constant pain. The connective tissue bands penetrating a fatty tissue of a dactyl and bridging actually a skin with a periosteum, interfere with edema diffusion on periphery. The tension of these intersections causes a megalgia in a dactyl. At hypodermic panaritiums pus tends to diffusion to depth.
Paronychia - the inflammation of the periungual platen accompanied by its painful tumescence and a hyperemia of surrounding tissues. At survey overhand of the struck periungual platen over a nail plate is defined. The palpation of hydropic tissues of a dorsum of a nail phalanx where inflammatory process is localised, is painful. Because of the accruing inflammatory phenomena patients quickly enough lose working capacity.
In some cases at a paronychia pus inpours under a nail plate, peeling to peel out last in a lateral or proximal part. Thus the purulent exsudate appears through through flaked fingernail edge.
The hyponychial panaritium is characterised by a clump of an inflammatory exsudate under a nail plate, peeling to peel out last from a nail bed on all its extent or in a separate field. At a palpation the vacillation of a nail plate becomes perceptible, its bracing to a bed is lost, there is only strong a fingernail affixion in proximal part at a matrix. Approximately the pus clump under all nail plate or on small region is visible to a distal, proximal or lateral part of a nail bed.
The edema and dermahemia at hyponychial panaritiums are not expressed. The basic symptom is the pulsing, arching pain in the field of a nail phalanx. Morbidity becomes perceptible at a palpation or a percussion of a nail plate.
The osteal panaritium educes, as a rule, again at transition of pathological process from soft tissues of a dactyl on a bone basically at hypodermic panaritiums. In such cases after dissecting of a hypodermic panaritium after the short-term season of imaginary enriching of a condition, reduction of an edema also be ill recover does not come. The pain in a dactyl has stupid constant character, from a wound the poor purulent discharge sometimes with fine osteal sequesters does not stop. A phalanx it is claviform thickens, its palpation becomes painful.
On roentgenograms of a dactyl signs of destruction of a bone are defined only to the extremity of 2nd or the beginning of 3rd week. Operation should be effected, not waiting obvious radiological destructive changes, being guided by a clinical picture of disease.
Hand phlegmons. The edema and a hyperemia of tissues, disturbance of function of a hand, aboriginal rise in temperature, morbidity concern aboriginal signs of phlegmons of a hand at a palpation.
The phlegmon of an eminence of I dactyl (thenar) is accompanied by a sharp edema of a thenar and radial edge of a dorsum of a hand. A sharp pain at a palpation, a strain of tissues, restriction of motility of hydropic tissues of a thenar, a smoothness of a palmar dermal cord - characteristic symptoms of a phlegmon of a thenar. Quite often purulent exsudate extends on edge of the first back interosseous muscle on a dorsal surface of a hand. In some cases purulent fusion of the connective tissue septum parting a cleft of a thenar and median palmar space, with formation of a phlegmon of a median palmar recess is observed.
The phlegmon of an eminence of a little finger (hypothenar) is not accompanied by the phenomena of the expressed intoxication. Moderately expressed edema, a hyperemia and a strain of tissues, morbidity are characteristic at a palpation in the field of a hypothenar, pain intensifying at locomotions of V dactyl.
At a phlegmon of median palmar space the purulent exsudate accumulates between a palmar sheath and the thin fascial plate covering tendons of flexors of dactyls, or between a fascia covering from the palmar party interosseous muscles, and a back surface of tendons of flexors of dactyls. Disease is accompanied by the expressed implications of an intoxication, a fervescence, a headache, changes in peripheric blood. At hand survey the central part of a palm protrudes, the skin is exerted, cords are smoothed, fluctuation to define it is not possible. At a palpation of the locus of an inflammation patients feel a strong pain. The edema of a back of the hand is considerably expressed, II-V dactyls are a little incurvated in interphalangeal joints, attempt of active or their passive extension leads to a tension infiltrate a palmar sheath and thereof to pain intensifying. Overdue and irrational measures of treatment of a phlegmon of median palmar space become complicated pus break in a thenar cleft, and also its diffusion on canals of worm-shaped muscles on a back of the hand.
At a hypodermic phlegmon of a dorsum of a hand which, as a rule, educes after damage of integuments of a dorsum of a hand, the edema and a hyperemia of tissues have diffuse character, suppurative focus borders to establish difficultly. By a careful palpation of tissues it is possible to receive representation about the locus of a purulent ramollissement of a fat.
Podaponevrotichesky phlegmons of a dorsum of a hand result from infection contamination penetration deeply under a sheath at chipped wounds. At this kind of a phlegmon the dense infiltrate which is accompanied by an edema and a hyperemia of a dorsum of a hand is defined. At purulent processes of a palmar surface of a hand infection contamination drift on its back on absorbent vessels or on canals of worm-shaped muscles is possible. In these cases to an edema of a back of the hand which, as a rule, accompanies the inflammatory phenomena on a palmar surface, the dermahemia, diffuse morbidity join at a palpation of a back of the hand.
Furuncle, hand anthrax. The edema, a hyperemia and sharp morbidity at a palpation of a dorsum of a hand or dactyls, presence of a necrotic hinge are furuncle symptoms. At an anthrax the specified symptoms are expressed more sharply: there are some necrotic hinges, in larger degree the general condition of the patient suffers, the intoxication phenomena are quite often expressed (the headache, the delicacy, the raised body temperature), educe a regional lymphadenitis and a lymphangitis.
Treatment. In an is serous-infiltrative phase of an inflammation apply spirituous trays, an electrophoresis of Trypsinum, chymotrypsin, an antibioticotherapia, including regional intravenous introductions of antibiotics, UHF-THERAPY. The first sleepless night spent by the patient in connection with a pain in the field of a dactyl, serves as the indication to operation, as well as sharp morbidity at pressure upon the inflamed field of a dactyl, appearance of a firm tumescence in the field of dactyl pulp, an edema of surrounding tissues.
The great value in hand surgery has exact idea about topography of muscular branches of a median nerve as at damage of the last the important function of muscles of an eminence of I dactyl is broken. The median nerve on a hand is projected at proximal edge of the dermal cord abjointing range of a thenar from an average palmar part. The so-called prohibited zone where the first most important muscular branch of a median nerve settles down, is defined between three conditional lines. The first line spend from radial edge of a distal dermal cord of a wrist to ulnar edge of a dermal cord of the establishment of V dactyl, the second line - from the articulate cleft formed by I metacarpal and big polygonal bone to the third interdigital interspace, the third line - from I metacarpophalangeal joint to horizontally ulnar party of a palm. The distal establishment of a prohibited zone is formed by a straight line spent from a place of crossing of the first and third lines to second, that the angles between these direct and second and third lines were peer. During operations on a hand it is necessary to be especially attentive in this region.
At hypodermic panaritiums of nail and average phalanxes, hyponychial panaritiums and paronychias operation can be executed без6олезненно year a conduction anaesthesia. The preliminary applying a tourniquet at the dactyl establishment allows to carry out operation without blood, well to be guided in a wound and carefully to delete necrotizing tissues.
At serious forms of panaritiums (tendinous, a pandactylitis), phlegmons of a hand of operation carry out under an intravenous aboriginal anaesthesia. At serious phlegmons of a hand and a phlegmon of space operation carry out under an intravenous narcosis.
At operations on dactyls and a hand it is necessary to use ophthalmic instruments (a scalpel and acuminate scissors). It allows to effect adequate cuts, it is convenient to manipulate in a wound, to make thrifty use of teleorganic tissues, completely to delete necrotic tissues.
Depending on diffusion of purulent process effect linear one-or bilateral lateral cuts. In all cases, except for a dermal, hyponychial panaritium and dermal abscesses of a palm, operation finish a wound drainage. For this purpose use a rubber window tube which gives the chance periodically or to irrigate constantly a purulent lumen with solutions of antiseptic agents or proteolytic enzymes that promotes fast excision of pus, pain reduction, tearing away of necrotic tissues and faster wound repair.
At dermal and hyponychial panaritiums run low only an exfoliating part of a false skin or a nail plate, the traumatic surface is flushed by 3 % solution of peroxide of hydrogen, and integuments round it alcoholize.
To dissecting of a tendinous vagina apply intermittent secund and didymous linear lateral cuts on average and basic phalanxes. A drainage of a tendinous vagina carry out by means of a window tube in a cross-section direction, which spend over a tendon not to damage its mesentery.
At osteal - articulate panaritiums effect didymous linearly-lateral cuts, dissect and treat an is purulent-necrotic lumen. Necrotic tissues and sequesters delete, resect the variated bone, a wound drain a window tube. At a pandactylitis II - V dactyls for prevention of generalisation of an infection contamination and liquidation of purulent process at unsuccessfulness of other kinds of therapy resort to a dactyl exarticulation. At a pandactylitis of I dactyl it is not necessary to hurry up with this operation as, even having lost ability to incurvate unbend to locomotions, I dactyl keeps opposition function without which practical activities of the human considerably decrease.
Carrying out operations at palm phlegmons, it is necessary to consider, that on a back of the hand the edema is constantly observed. At the expressed edema of a back of the hand here never it is necessary to do a cut before pyesis possibility on dactyls and a palm will be excluded. However if after abscess dissecting on a dactyl and a palm the body temperature does not decrease, and on a back of the hand the edema becomes less dense and the skin over it reddens, it is necessary to consider, that the collateral edema has passed in a pyesis.
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