Panaritium (purulent inflammation of the tissues of the fingers and toes)

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Panaritium is an acute purulent inflammatory process of the tissues of the fingers, and sometimes the toes. In this case, the superficial and deep tissues of the fingers are susceptible to damage. Despite the fact that the disease can develop due to the slightest mechanical damage, it is not recommended to ignore this problem.

There are several types of disease:

• subcutaneous panaritium;
• periungual;
• articular;
• bone panaritium (in this case, not only tissues are damaged, but also bones, and suppuration spreads to the periosteum and to the bone itself);
• bone-statutory;
• tendon panaritium.

When treating Panaritium, doctors at the BIOSS clinic use both time-tested and the latest developments and proprietary techniques.

Our clinic employs the best doctors in Moscow who have extensive experience in the treatment of Panaritium :

• Zaets Sergey Fedorovich, surgeon, candidate of medical sciences.

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Panaritium is an acute purulent inflammatory process that is localized in the soft tissues of the fingers (less commonly, toes) and occurs on the palmar surface of the fingers. Purulent inflammation on the dorsum of the fingers is not classified as panaritium, with the exception of processes in the nail area.

Panaritium develops as a result of the activity of pyogenic microorganisms (most often Staphylococcus aureus ), which penetrate the tissue through minor skin lesions (abrasions and small wounds on the hands), which can sometimes go unnoticed. In this case, characteristic swelling, redness and pain are observed in the area of ​​the affected finger. In the initial stages, conservative treatment is still possible. In severe forms of the disease, chills and fever are observed. The pain can be sharp, throbbing and interfere with normal sleep. An abscess begins to form on the affected area of ​​the hand.

The thing is that on the palmar surface of the fingers there are many important anatomical formations: tendons and tendon sheaths, nerves, blood vessels, joint capsules, etc. The subcutaneous tissue in this area has a special structure. Numerous elastic and strong fibers run 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, reminiscent of a honeycomb.

This structure, on the one hand, prevents the spread of inflammation “along”, on the other hand, it creates favorable conditions for the penetration of the purulent process deep into the tissues. That is why with panaritium, rapid progression is possible, involving tendons, bones and joints, or even all tissues of the finger.

When an abscess forms, surgery is necessary, because the structural features and location of soft tissues in this area, as noted above, contribute to the spread of suppuration in depth. Without proper treatment, serious complications are likely, so if you suspect panaritium, you should immediately consult a doctor.

Panaritium is more often observed in children, as well as in young and middle-aged people - from 20 to 50 years. According to statistics, three quarters of patients fall ill after microtrauma received at work. The most common localization is the 1st, 2nd and 3rd fingers of the right hand. The development of felon is promoted by both external (cooling, vibration, exposure to chemicals) and internal (weakened immunity) factors.

Causes

Panaritium is a bacterially caused nonspecific inflammation. Most often, pyogenic staphylococci and streptococci are the causative agents. But the participation of other pathogenic microorganisms (for example, yeast-like fungi) and mixed infections cannot be ruled out. Sometimes the herpetic form of the disease also occurs.

The route of penetration of pathogens is exclusively exogenous. In most cases, the entry points are minor skin lesions. Therefore, patients with panaritium may have a history of injections with sewing needles and plant thorns, cuts (including when cutting nails), wounds after torn hangnails, removed or remaining splinters, and abrasions.

An increased risk of developing felon is observed in people whose work activities or hobbies involve processing wood, metal and other surfaces. Fishermen and workers in fish processing plants are prone to this disease. Less commonly, infection occurs through animal bites, lacerations and crushed wounds, and open fractures of the fingers.

The development of felon is promoted by:

• incorrect or untimely treatment of injuries received;
• using tools that have not been cleaned for a long time for manicure;
• excessive cutting of the edges of the nail plates;
• wearing tight, poorly ventilated shoes;
• repeated long-term macerations of the skin;
• the presence of diabetes mellitus, polyhypovitaminosis and immunodeficiency conditions of any origin;
• chronic microcirculation disorders in the fingers caused by vibration, repeated hypothermia, exposure to toxic compounds (metals, mineral oils, quicklime).

In most cases, the disease is caused by injuries at work and existing occupational predisposing hazards. Domestic reasons account for 10-15%.

Classification of panaritiums

Taking into account the location and nature of the affected tissues, the following types of panaritium are distinguished:

• Cutaneous panaritium is the mildest form: an abscess forms in the thickness of the skin.
• Periungual panaritium (paronychia) - inflammation is localized in the area of ​​the periungual fold.
• Subungual felon - develops under the nail plate.
• Subcutaneous felon - occurs in the subcutaneous tissue of the palmar surface of the fingers.
• Bone panaritium - a distinctive feature is the involvement of bone in the purulent process.
• Articular felon - develops in the interphalangeal or metacarpophalangeal joints.
• Osteoarticular felon - usually occurs with the progression of articular felon, when inflammation spreads to the articular ends of the phalangeal bones.
• Tendon felon - localized in the tendon area.

COMPLICATIONS OF PENARITIA OR WHAT HAPPENS IF IT IS NOT TREATED OR TREATED INCORRECTLY

With advanced panaritium, inflammation may spread to deeper tissues with the development of pandactylitis. The latter is difficult to treat and often leads to amputation of the finger. The transition of purulent inflammation to the tendon and the lack of timely surgical treatment causes necrosis of the tendon with loss of active movements in the finger. Along the tendon sheath, the purulent process quickly spreads to the hand with the development of phlegmon of the hand, the treatment of which requires extensive surgical interventions.

Articular panaritium often leads to the formation of contractures and stiffness in the affected joint.

Bone panaritium often leads to the development of chronic osteomyelitis of the finger with a recurrent course, accompanied by partial or complete loss of mobility.

Therefore, self-medication for felon is dangerous and can lead to tragic consequences. A positive outcome for this disease is only possible if you seek medical help early. Take care of your health. It is better to overestimate the severity of your symptoms than to seek medical help late.

Predisposing factors and reasons for the development of panaritium

The direct cause of panaritium is most often Staphylococcus aureus , which penetrates the tissue through wounds, abrasions, injections, cracks, splinters or hangnails, which most often go unnoticed, because look so insignificant that the patient simply does not pay attention to them. Less commonly, panaritium is caused by gram-negative and gram-positive bacilli , streptococcus , Escherichia coli , Proteus , as well as anaerobic non-clostridial microflora and pathogens of putrefactive infections .

External factors contributing to the development of felon include:

• systematic cooling,
• hydration,
• vibration,
• maceration,
• contamination or exposure to irritants.

Internal factors that increase the likelihood of felon occurring are:

• endocrine diseases,
• hypovitaminosis,
• metabolic disorders,
• decreased immunity.

Symptoms of felon

Symptoms of panaritium are distinguished depending on the form of the disease. However, in any form, a number of common symptoms are observed: in the initial stages of felon, there is redness, slight swelling and mild or moderate pain, possibly a burning sensation; then the swelling increases, the pain intensifies, becomes intense, bursting, tugging, depriving sleep.

A purulent focus forms in the area of ​​inflammation, which is clearly visible in superficial forms of panaritium. The formation of an abscess may be accompanied by weakness, increased fatigue, headache and increased 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 in this area turns red, then a limited area of ​​the epidermis peels off in the center of the redness. A blister forms, filled with a cloudy, bloody or grayish-yellow liquid that is visible through the skin. At first the pain is mild, then it gradually intensifies and becomes throbbing. 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 panaritium, the general condition does not suffer; with lymphangitis, fever, weakness, and weakness are possible.

Periungual felon (paronychia)

As a rule, it develops after an unsuccessful manicure or is a complication of hangnails and cracks in the periungual fold in people who work physically. Initially, local swelling and redness are noted, then the process quickly spreads, covering the entire nail fold. An abscess forms quite quickly, visible through the thin skin of this area. Severe pain occurs in the area of ​​inflammation, disturbing sleep, but the general condition is almost unaffected. Lymphangitis with 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 to chronic . As the process progresses, pus can break through under the base of the nail, spread into the subcutaneous tissue of the palmar area, onto the bone and even the distal interphalangeal joint.

Subungual panaritium

It is usually a complication of paronychia, however, it can also develop primarily as a result of a splinter, a puncture wound in the area of ​​the free edge of the nail, or during suppuration of a subungual hematoma. Since the developing abscess in this area is “pressed down” by a hard and dense nail plate, subungual panaritium is characterized by extremely intense pain, general malaise and a significant increase in temperature. The nail phalanx is swollen, pus is visible under the nail.

Subcutaneous panaritium

The most common type of panaritium. It usually develops when small but deep puncture wounds become infected (for example, when pricked by a plant thorn, an awl, a fish bone, etc.). Initially, slight redness and local pain appear. Over the course of several hours, the pain intensifies and becomes throbbing. The finger swells. The patient's general condition can either remain satisfactory or significantly worsen. 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 from an infected open fracture or become a consequence of subcutaneous panaritium when infection spreads from soft tissue to the bone. Characteristically, the processes of bone melting (osteomyelitis) predominate 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 pain and cannot sleep.

The affected phalanx increases in volume, which is why the finger takes on a flask-shaped appearance. The skin is smooth, shiny, red with a cyanotic tint. The finger is slightly bent, movement is limited due to pain. Unlike subcutaneous panaritium, with the bone form it is impossible to determine the area of ​​maximum pain, since the pain is diffuse. Chills and fever are noted.

Articular felon

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 panaritium). Initially, there is slight swelling and pain in the joint when moving.

Then the pain intensifies, movements become impossible. The swelling increases and becomes especially pronounced on the dorsum of the finger. Palpation determines the tension of the joint capsule. Subsequently, a fistula forms on the back of the finger. Primary felons can end in recovery; with secondary felons (caused by the spread of suppuration from adjacent tissues), the outcome is usually amputation or ankylosis.

Tendon panaritium (purulent tenosynovitis)

Like other types of panaritium, it can develop either through direct penetration of the infection or when it spreads from other parts of the finger. The finger is uniformly swollen, slightly bent, intense pain is noted, sharply intensifying when attempting passive movements. When pressure is applied along the tendon, sharp pain is detected. Redness may not be noticeable. There is a significant increase in temperature, weakness, and lack of appetite. Confusion and delirium may occur.

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, moving to the muscles, bones, soft tissues of the palm and even the forearm. If left untreated, the tendon completely melts and the finger loses its function.

Possible complications

Possible complications of panaritium are associated with the spread of purulent infection beyond the finger or with the consequences of a previous illness. These include:

• Sepsis, that is, generalization of infection with the formation of secondary multiple purulent foci in various organs, the development of DIC syndrome and multiple organ failure.
• The spread of the process to the synovial bursae of the hand and even the forearm with the development of corresponding purulent tendovaginitis. This is most likely with panaritium of the 1st and 5th fingers of the hand, because their flexor sheaths continue to the wrist joint and even extend to the forearm. But the synovial bursae of the palmar surfaces of the II-IV fingers of the hand end blindly at the level of the metacarpophalanal joints.
• Phlegmon of the hand, with the spread of infection from the fingers most often occurring under the aponeurosis.
• Osteomyelitis of the metacarpal and carpal bones.
• Vascular thrombosis with the development of acute ischemic tissue necrosis, periphlebitis and thrombophlebitis of the extremities.
• Purulent lymphadenitis of regional lymphatic vessels. In this case, the so-called lymphatic panaritium is diagnosed. This disease is characterized by a discrepancy between the moderate severity of signs of inflammation of the finger with pronounced symptoms of lymphogenous spread of infection. Moreover, sometimes lymphadenitis and general intoxication are detected even before the manifestation of the panaritium itself.
• Contractures of the fingers, which is a consequence of the articular and tendon forms of the disease.

Diagnostics

Diagnosis of panaritium is aimed at excluding other infectious and inflammatory diseases of the hand (or foot), and at clarifying the nature and depth of damage to the fingers. Patient examination includes:

• Inspection. The doctor evaluates external changes in the affected area, identifies signs of intoxication, and checks the condition of regional (axillary) lymph nodes. For local examination, a button probe is used, which allows you to determine the area of ​​greatest pain and, if necessary, the depth of the purulent wound.
• Taking swabs if there is discharge or an open wound. Allows you to conduct a bacteriological study to determine the type of pathogen and its sensitivity to basic antibacterial agents. True, the result of such an analysis can be obtained no earlier than 5-7 days, which is due to the need to expect the growth of microorganisms in various media in the incubator.
• Survey radiography, targeted, in 2 projections. It is carried out if there is a suspicion of articular and bone form. But it should be taken into account that osteomyelitis of the terminal phalanx in most cases is verified radiographically only at 2-3 weeks of the disease, while small crumbly bone sequesters are detected from the first days.
• Diaphonoscopy - transillumination of the tissues of the affected finger. The source of inflammation is visible as a darkening, which allows you to determine its approximate size and shape.
• General clinical blood test to determine the severity of the general inflammatory reaction by assessing the level of ESR, leukocytosis and the nature of the shift in the leukocyte formula.

The examination plan also often includes tests to identify predisposing and aggravating factors for the disease. This includes testing blood glucose levels (to rule out diabetes) and ruling out syphilis.

The clinical picture of panaritium requires differential diagnosis with onychomycosis (especially when the toes are affected), erysipelas, boils, and carbuncles. And sometimes the doctor has to exclude a special pathology, the so-called chancroid-felon. This is a rare form of primary syphilis, when microdamages in the epidermis of the fingers become the entry point for treponema pallidum. This is possible for health workers who, due to their occupation, come into contact with potentially contaminated biological fluids and tissues. At risk are pathologists, neurologists and anesthesiologists-resuscitators who perform spinal punctures, nursing staff involved in infusions, and some others.

Diagnosis of felon

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. It should be taken into account that, unlike bone panaritium, in the articular form of the disease, changes are not immediately detected and may be mildly expressed. Therefore, to clarify the diagnosis, comparative radiographs of the healthy finger of the same name on the other hand should be prescribed.

Treatment of felon

Surgeons treat felons. 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 can be prescribed conservative therapy: darsonval, UHF, thermal procedures.

In the later stages of superficial panaritium, as well as at all stages of the bone and tendon form of the disease, surgery is indicated. The opening of the panaritium is supplemented with drainage so as to ensure the most effective outflow from the fiber divided into cells.

Surgical tactics for bone or joint felon are determined by the degree of preservation of the affected tissues. In case of partial destruction, resection of the damaged areas is performed. In case of total destruction (possible with bone and osteoarticular panaritium), amputation is indicated. In parallel, drug therapy is carried out aimed at combating inflammation (antibiotics), reducing pain and eliminating the phenomena of general intoxication.

How to treat felon: basic principles

If panaritium develops, treatment at home is carried out exclusively under the supervision and prescription of a surgeon. It is possible to perform so-called minor surgical interventions on an outpatient basis. And if symptoms increase and the therapy is ineffective, hospitalization in the department of purulent surgery is advisable. The treatment tactics for panaritium depend primarily on the type of inflammation and the depth of tissue damage. At the catarrhal-infiltrative stage of the disease, conservative methods are used. The goal of such therapy is to localize inflammation, fight the pathogen, reduce the severity of edema and other local manifestations.

The appearance of a twitching pain, a wave of hyperthermia and the first sleepless night are signs of inflammation turning into a purulent form. This requires surgical treatment to evacuate pus, remove necrotic tissue and create a sufficient outflow path for the resulting exudate. The volume and technique of the operation are determined by the shape of the panaritium. If possible, drainage is placed in the wound, which prevents the edges of the wound from sticking together and facilitates self-evacuation of purulent exudate. The exception is the cutaneous form; in this case, only a wide opening of the panaritium (subepidermal bladder) is performed.

The surgical treatment performed is necessarily complemented by conservative measures, washing the postoperative wound and dressings with antiseptic and anti-inflammatory agents. The use of Levomekol for panaritium is the most common postoperative measure.

If the main symptoms do not go away after surgery, a repeated targeted examination is necessary to exclude the development of deep forms of the disease and complications.

Conservative treatment

Conservative treatment may include:

• The use of broad-spectrum antibiotics, preferably with a bactericidal effect. In most cases, the choice falls on penicillin or cephalosporin drugs; lincomycin is also used. All others are the drugs of choice if the treatment is ineffective. Antibiotics for finger felon can be used not only for systemic, but also for local therapy. The practice is to puncture the source of inflammation, wash the purulent wound, applications, ointments (for example, Oflomelid). Antibiotics are also sometimes given intravenously retrogradely (without removing the tourniquet).
• Local prolonged hypothermia. It can be effective at the catarrhal stage of cutaneous and developing subcutaneous panaritium.
• Taking NSAIDs for pain relief and anti-inflammatory purposes. It is more of an auxiliary measure.
• Compresses and applications using anti-inflammatory drugs. The most commonly prescribed are Dimexide (in appropriate dilution), Chlorhexidine, Chlorphyllipt in the form of an alcohol solution, Vishnevsky ointment, Levomekol. But ichthyol ointment in the treatment of felon is currently considered ineffective; a clinically significant effect from its use is noticeable mainly in the herpetic nature of the disease.
• Warming and alcohol compresses on the area of ​​inflammation.
• Physiotherapy (UHF, ultraviolet, iontophoresis).
• Immobilization, allowing to create functional rest of the affected part of the limb. Auxiliary measure.

Conservative therapy is also possible in the early stages of deep forms of panaritium.