Cellulitis hand is a diffuse purulent lesion that spreads through the cellular spaces of the palm and the tissues of the back of the hand. The main etiological factor is called staphylococcal infection, less often the disease is caused by streptococci, gram-negative bacteria. The disease is manifested by severe pain in the affected area, swelling and hyperemia of the skin, general intoxication syndrome. To diagnose pathology, a physical examination, ultrasound and radiography, a complex of laboratory tests are carried out. Treatment includes drug therapy, surgical autopsy and drainage of purulent cavities.
L03.0 Cellulitis and acute lymphangitis of finger and toe
Panaritia and cellulitis hand account for 15-30% of all purulent diseases in outpatient surgery. They cause about 1% of patients’ visits to the polyclinic and 8-10% of cases of temporary disability among young and middle-aged people. Although the etiopathogenesis of the disease is well studied, doctors face a number of difficulties in the treatment: the need for traumatic surgical interventions, difficulties in selecting antibiotic therapy, a high risk of spreading the purulent process to the overlying parts of the arm.
Cellulitis hand occurs under the influence of pathogenic bacterial flora. About 50-65% of cases are caused by Staphylococcus aureus and hemolytic staphylococci, 10-12% ‒ streptococci, 7-20% of cases are provoked by gram-negative microorganisms and bacterial associations. Prognostically unfavorable are the cellulitis of the hand caused by a combination of aerobic and anaerobic flora.
The main entrance gates of infection are abrasions and burrs on the nail phalanges of the fingers, through which pathogens penetrate into soft tissues. In women, purulent inflammation of the brush can develop after manicure in non-sterile conditions, if the master does not follow the rules of disinfection of tools. Less often, cellulitis are formed after animal bites, direct stab wounds.
Microtrauma of the skin of the hands periodically occur in every person, but the cellulitis hand develops much less often. Predisposing factors are necessary for the formation of inflammation: microcirculation disorders, vibration sickness, frequent hypothermia (walking without gloves, working in cold workshops). The probability of suppuration of soft tissues increases in people with vitamin deficiency, immunodeficiency, diabetes mellitus. An independent risk factor is the intake of glucocorticoids, immunosuppressive drugs.
The pathogenetic features of the disease are determined by the type of pathogen. With staphylococcal infection, there is a rapid purulent melting of tissues and self-restriction of the focus due to the action of the coagulase enzyme. Necrosis of cellular spaces caused by necrotoxin, leukocidin, hyaluronidase and other aggression factors is characteristic.
With streptococcal infection, severe edema develops, inflammation quickly spreads through the tissues. When soft tissues are infected with anaerobic microorganisms, a special type of lesion is formed. The multiplication of bacteria causes crepitation of the palm or back surface, limited necrosis zones appear on the skin. The purulent focus is accompanied by a sharp fetid smell, which is heard at a distance from the patient.
In practical surgery, there are two stages of cellulitis development: serous-infiltrative, in which there is no purulent exudate, and purulent-necrotic, characterized by extensive melting and necrosis of tissues. For the choice of treatment tactics and the scope of surgical intervention, the classification of the disease by its spread to anatomical structures plays an important role:
- Subcutaneous tissue – interdigital and supra-aponeurotic (subcutaneous) cellulitis).
- Fascial-cellular zones are the cellulitis of the tenar, hypotenar, median palmar space and the Pirogov-Paron zone.
- Tendon bags are the primary and secondary V-shaped cellulitis hand.
- The back surface is subcutaneous and subaponeurotic cellulitis of the back of the hand.
With serous-infiltrative type of inflammation, patients experience moderate pain in the fingers and hands. Unpleasant sensations do not have a clear localization, they increase when you lower your hand down. Above the inflammatory focus, the skin is red, hot and edematous. External symptoms are most pronounced on the back of the hand. Due to the pain, fine motor skills are limited, there are problems with typing, driving a car, doing housework.
When the disease passes into the purulent-necrotic stage, the pain increases and becomes pulsating. Pain syndrome interferes with sleep, so cellulitis is characterized by a symptom of the “first sleepless night”. To reduce discomfort, patients avoid sudden movements and mechanical influences, lift the brush up and fix it with a healthy hand. Hyperemia and swelling of tissues increases, occasionally the skin acquires a purplish-bluish color.
The clinical picture depends on the location of the purulent focus. Tenar’s cellulitis is characterized by severe pain, hyperemia and swelling in the area of the elevation of the thumb, when the hypotenar is affected, similar symptoms occur on the part of the little finger. Inflammation of the median space is manifested by swelling of the central part of the palm, severe swelling on the back of the hand.
The cellulitis of the brush is accompanied by a syndrome of endogenous intoxication, which is caused by the action of the bacteria themselves and their waste products. Against the background of the disease, the body temperature rises, and its values correlate with the severity and prevalence of the purulent process. Patients complain of decreased performance, severe weakness, chills and a complete lack of appetite.
The most severe is the U-shaped cellulitis, which affects all fascial-cellular spaces. Through the channels of the worm-like muscles, purulent exudate spreads to the back of the hand, forming a total inflammatory focus. In the future, purulent-necrotic processes can seize the wrist and move to the overlying parts of the limb. Untreated cellulitis are fraught with osteomyelitis, contractures, sepsis and septicopiemia.
The consultation of a surgeon, examination and palpation of the affected area plays a crucial role in the diagnosis. To clarify the localization of pain, a button probe is used, and the safety and volume of movements in the joints of the fingers and hand are additionally assessed. In addition to physical examination, the following examination methods are prescribed:
- Ultrasound of soft tissues. During sonography, a violation of the structure of soft tissues and cellular spaces is determined. Purulent inflammation on ultrasound is visualized as a darkening area without clear boundaries.
- Radiography of the hand. Radiological signs of destruction appear with bone destruction developing at 2-3 weeks of the disease. Surgical treatment of cellulitis is carried out as early as possible, in this case there are no significant changes on the X-ray.
- Blood test. According to the results of the hemogram, leukocytosis is determined with a shift of the formula to the left, a sharp increase in ESR, an increase in leukotoxicity indices. The number of acute-phase proteins is also increasing, the biochemical parameters of the blood are changing.
With the classic clinical picture of the disease, the diagnosis is established unmistakably. Occasionally, doctors have difficulties with determining the type of cellulitis, on which the place and method of surgical opening of the abscess will depend. Instrumental visualization methods help to clarify the diagnosis. In case of doubtful symptoms, differential diagnosis is carried out with the initial period of boils and carbuncles of the hand.
At the initial stage of the disease, complex drug treatment in combination with immobilization of the affected limb is indicated. For immobilization, plaster splints are used, which are superimposed to the middle of the forearm. At the same time, the fingers are placed in a functionally advantageous position, which is important for the subsequent restoration of motor functions. The main components of the therapeutic program:
- Antibiotic therapy. Taking into account the severity of the process, drugs for oral and parenteral administration are used. According to individual indications, local routes of administration are used: endolymphatic, regional intravenous under a tourniquet.
- Anti-inflammatory therapy. NSAIDs are widely used from medications. Local hypothermia, elevated limb position, wet-drying bandages are also shown.
- Symptomatic therapy. To reduce pain, patients are prescribed different groups of systemic analgesics. In severe forms of pathology, complex detoxification therapy is carried out.
With the purulent-necrotic nature of the cellulitis hand, surgical intervention is required. Treatment is performed as soon as possible to prevent complications. On an outpatient basis, an autopsy of the lesion, removal of necrotic tissues, antiseptic treatment and adequate drainage are carried out. The volume of surgical treatment of cellulitis depends on its localization and prevalence. General or intraosseous anesthesia is used for anesthesia.
Prognosis and prevention
The cellulitis of the hand are subject to successful treatment, provided early access to a doctor and complex therapy. A less favorable prognosis for patients with U-like purulent processes, lesions of the bone-articular structures of the hand. To prevent purulent inflammation, it is recommended to avoid injuries to fingers and palms, get rid of the habit of biting nails and the skin around them, and observe safety precautions at work.