Panaritium is an acute purulent inflammatory process localized in the tissues of the fingers (less often – toes) and occurs on the palm surface of the fingers. It is manifested by pain, swelling, redness, an increase in body temperature, symptoms of general intoxication. It is diagnosed on the basis of complaints and the results of an objective examination. If bone and joint forms of the disease are suspected, radiography is necessary. Conservative treatment is possible in the initial stages. When an abscess is formed, an autopsy, drainage is required, amputation is indicated in severe cases.
ICD 10
L03.0 Phlegmon of the fingers of the hand and foot
Meaning
Panaritium – acute suppuration of the fingers (less often – toes). It is one of the most common pathologies in purulent surgery. It develops as a result of the vital activity of pyogenic microorganisms (most often Staphylococcus aureus), penetrating into the tissues through minor skin lesions. With panaritia, swelling, redness and pain in the finger area are noted. In severe forms, chills and fever are observed. The pain can be sharp, throbbing, sleep-deprived. Conservative treatment is possible in the early stages, and surgery is necessary in the later stages.
Causes
The immediate cause of the pathology is most often Staphylococcus aureus, which penetrates into the tissues through wounds, abrasions, injections, cracks, splinters or burrs, which sometimes go unnoticed or look so insignificant that the patient simply does not pay attention to them. Less often, panaritium is caused by gram-negative and gram-positive bacillus, Streptococcus, E. coli, proteus, as well as anaerobic non-clostridial microflora and pathogens of putrefactive infection.
The external factors contributing to the development of panaritium include systematic cooling, humidification, vibration, maceration, pollution or exposure to irritating substances. Internal factors that increase the likelihood of panaritium are endocrine diseases, hypovitaminosis, metabolic disorders and decreased immunity.
Panaritium is more often observed in children, as well as young and middle–aged people – from 20 to 50 years. According to statistics, three quarters of patients get sick after a microtrauma received at work. The most common localization is the I, II and III fingers of the right hand. Both external (cooling, vibration, exposure to chemicals) and internal (weakening of immunity) factors contribute to the development of panaritium.
Pathanatomy
On the palmar surface of the fingers there are many important anatomical formations: tendons and tendon sheaths, nerves, vessels, joint capsules, etc. Subcutaneous tissue in this area has a special structure. Numerous elastic and durable fibers go from the skin to the palmar aponeurosis. In addition, longitudinal bundles of connective tissue are located in the thickness of the fiber. As a result, the fiber is divided into small cells resembling honeycombs.
Such a structure, on the one hand, prevents the spread of inflammation “along”, on the other hand, creates favorable conditions for the penetration of the purulent process deep into the tissues. That is why rapid progression with the involvement of tendons, bones and joints, or even all the tissues of the finger, is possible with panaritia.
Classification
Taking into account the location and nature of the affected tissues , the following types of panaritium are distinguished:
- Cutaneous. The easiest form. An abscess forms in the thickness of the skin.
- Periarticular. The inflammation is localized in the area of the periarticular roller.
- Podnogtevoy. Develops under the nail plate.
- Subcutaneous. It occurs in the subcutaneous tissue of the palm surface of the fingers.
- Bone. A distinctive feature is the involvement of the bone in the purulent process.
- Articular. Develops in the interphalangeal or metacarpophalangeal joints.
- Osteoarticular. Usually occurs with the progression of articular panaritium, when the inflammation passes to the articular ends of the bones of the phalanges.
- Tendon. It is localized in the tendon area.
Symptoms
Symptoms may vary depending on the form of the disease. Nevertheless, a number of common manifestations are observed in all forms. In the initial stages of panaritium, there is redness, slight swelling and mild or moderate pain, possibly burning. Then the swelling increases, the pain intensifies, becomes intense, bursting, jerking, sleep-deprived.
In the area of inflammation, a purulent focus is formed, which is clearly visible in the superficial forms of panaritium. The formation of an abscess can be accompanied by weakness, fatigue, headache and an increase in body temperature. Symptoms of intoxication are more pronounced in deep, severe forms of panaritium (bone, joint, tendon). In addition, each form of panaritium has its own characteristic symptoms.
Cutaneous panaritium
Usually occurs in the area of the nail phalanx. The skin turns red, then a limited area of the epidermis exfoliates in the center of the redness. A bubble is formed filled with a cloudy, bloody or grayish-yellow liquid that shines through the skin. Initially, the pain is indistinct, then they gradually intensify, become pulsating. This form of panaritium is often accompanied by stem lymphangitis, in which red stripes form on the forearm and hand along the inflamed lymph nodes. With uncomplicated panaritia, the general condition does not suffer, with lymphangitis, fever, weakness, and bruising are possible.
Periarticular panaritium
Paronychia, as a rule, develops after an unsuccessful manicure or is a complication of burrs and cracks of the periarticular roller in people of physical labor. Initially, there is local swelling and redness, then the process spreads rapidly, covering the entire nail roller. An abscess forms quickly enough, shining through the thin skin of this area. Severe pain occurs in the area of inflammation, disrupting sleep, but the general condition almost does not suffer. Lymphangitis in this form of panaritium is rarely observed.
Spontaneous opening of the abscess is possible, but its incomplete emptying can cause the transition of the acute form of panaritium into a chronic one. With the progression of the process, pus can break through under the base of the nail, spread to the subcutaneous tissue of the palmar area, to the bone and even the distal interphalangeal joint.
Podnogtevy panaritium
It is usually a complication of paronychia, however, it can also develop primarily – as a result of splinters, puncture wounds in the area of the free edge of the nail or with suppuration of a subarticular hematoma. Since the forming abscess in this area is “pressed down” by a rigid and dense nail plate, extremely intense pain, general malaise and a significant increase in temperature are characteristic of the sub-elbow panaritium. The nail phalanx is edematous, pus shines through under the nail.
Subcutaneous panaritium
The most common type of panaritia. It usually develops when small but deep puncture wounds are infected (for example, when pricked with a plant thorn, awl, fish bone, etc.). Initially, a slight redness and local pain appears. Within a few hours, the pain increases, becomes throbbing. The finger swells. The general condition of the patient can both remain satisfactory and significantly deteriorate. With ulcers under high pressure, chills and an increase in temperature to 38 degrees and above are noted. In the absence of treatment, insufficient or late treatment, the purulent process may spread to deep anatomical formations (bones, joints, tendons).
Bone panaritium
It can develop with an infected open fracture or become a consequence of subcutaneous panaritium when the infection spreads from soft tissues to bone. The predominance of bone melting processes (osteomyelitis) is characteristic over its restoration. Both partial and complete destruction of the phalanx is possible. In the early stages, the symptoms resemble subcutaneous panaritium, however, they are much more pronounced. The patient suffers from extremely intense throbbing pains, cannot sleep.
The affected phalanx increases in volume, which is why the finger acquires a flask-like appearance. The skin is smooth, shiny, red with a cyanotic tinge. The finger is slightly bent, movements are limited due to pain. Unlike subcutaneous panaritium with a bony form, it is impossible to determine the area of maximum soreness, since the pain is diffuse in nature. There is chills and fever.
Articular panaritium
It can develop as a result of direct infection (with penetrating wounds or open intra-articular fractures) or the spread of a purulent process (with tendon, subcutaneous and bone panaritia). Initially, there is a slight swelling and pain in the joint during movements.
Then the pain increases, movements become impossible. The swelling increases and becomes especially pronounced on the back of the finger. During palpation, the tension of the joint capsule is determined. Subsequently, a fistula forms on the back of the finger. Primary panaritia can end in recovery, with secondary panaritia (caused by the spread of suppuration from neighboring tissues), amputation or ankylosis usually becomes the outcome.
Tendon panaritium
Purulent tendovaginitis, like other types of panaritium, can develop both with direct penetration of infection and with its spread from other parts of the finger. The finger is evenly swollen, slightly bent, intense pain is noted, sharply increasing when trying passive movements. With pressure along the course of the tendon, sharp soreness is determined. Redness may not be pronounced. There is a significant increase in temperature, weakness, lack of appetite. Confusion and delirium are possible.
Tendon panaritium is the most severe and dangerous purulent inflammation of the finger. This is due to the fact that pus quickly spreads through the tendon sheaths, passing to the muscles, bones, soft tissues of the palm and even the forearm. In the absence of treatment, the tendon completely melts, and the finger loses its function.
Diagnostics
The diagnosis is made based on the patient’s complaints and clinical symptoms of the disease. To determine the shape of the panaritium and clarify the localization of the abscess, palpation is performed with a button probe. To exclude bone and articular panaritium, radiography is performed. At the same time, it should be borne in mind that, unlike bone panaritium, changes in the articular form of the disease are not detected immediately and may be weakly pronounced. Therefore, to clarify the diagnosis, comparative radiographs of the healthy finger of the same name on the other hand should be prescribed.
Treatment
Treatment is carried out by purulent surgeons. With superficial forms, the patient may be on an outpatient basis, with deep forms, hospitalization is necessary. In the early stages, patients with superficial panaritium may be prescribed conservative therapy: darsonval, UHF, thermal procedures. In the late stages of superficial panaritium, as well as at all stages of the bone and tendon forms of the disease, surgery is indicated. The opening of the panaritium is supplemented by drainage so as to ensure the most effective outflow from the fiber divided into cells.
Surgical tactics for bone or articular panaritia is determined by the degree of preservation of the affected tissues. In case of partial destruction, resection of the damaged areas is performed. With total destruction (possible with bone and bone-joint panaritia), amputation is indicated. In parallel, drug therapy is carried out aimed at combating inflammation (antibiotics), reducing pain and eliminating the phenomena of general intoxication.