Phlegmons of the hand

General features and classification

Purulent inflammation of the hand is always accompanied by localized hyperthermia, edema, tenderness upon palpation, and movement restriction.

Depending on the anatomical location of the focus, the following types of phlegmon are distinguished:

1. Subcutaneous (on the palmar surface).
2. Palmar episubfascial (between tendons and aponeurosis).
3. Subtendinous (deep to the flexors).
4. Thenar phlegmon (thenar).
5. Hypothenar phlegmon (hypothenar).
6. Subcutaneous phlegmon of the dorsal hand.
7. Subfascial phlegmon of the dorsal surface.

Features of localized forms

The development of the process in isolated spaces of the hand has a specific presentation.

• Hypothenar phlegmon (hypothenar): proceeds without pronounced general intoxication. Moderate edema, hyperemia, and tissue tension are observed. A distinguishing feature is that pain in the hypothenar area sharply increases with movements of the 5th digit.
• Thenar phlegmon (thenar): dangerous due to the development of complications. Purulent exudate can break through to the dorsal surface of the hand. If the septum between the thenar area and the midpalmar space melts, an extensive phlegmon of the midpalmar depression is formed.

Commissural phlegmon (callous abscess)

This form affects the distal part of the palm. The port of entry is deep cracks in the rough skin (callosities) in the projection of the 2nd–4th metacarpophalangeal joints.

Clinical picture:

• Severe pain syndrome.
• Edema involves the distal sections of both the palmar and dorsal surfaces.
• The fingers adjacent to the inflammatory focus are abducted and slightly flexed. Any attempt to extend them causes pain due to tension of the inflamed palmar aponeurosis.

Routes of pus spreading: the infection can extend to the dorsum of the hand through the oval gaps of the aponeurosis (involving the deep transverse ligament) or spread proximally along the lumbrical canals directly into the midpalmar space.

Midpalmar space phlegmon

A very severe condition with high fever, intoxication, and blood test abnormalities. Pus accumulates either above the flexor tendons or beneath them (anterior to the interosseous muscles).

Local status:

• The central part of the palm bulges, the skin is tense, and skin creases are smoothed out.
• The dorsal surface of the hand swells significantly.
• Digits 2–5 are in slight flexion; active or passive extension sharply increases pain due to tension of the infiltrated aponeurosis.
• If treated untimely, pus breaks through into the thenar cleft or extends to the dorsum of the hand.

Crossed (U-shaped) phlegmon

The most severe pathology among purulent lesions of the hand. Initially arises as purulent tenosynovitis of the 1st or 5th digit.

The infection spreads to the ulnar or radial synovial bursa. Proximally, these bursae are anatomically close to each other. In aggressive courses or delayed therapy, pus melts the walls and flows from the infected bursa into the healthy one. This forms a U-shaped communication.

Subsequently, pus can spread into the thenar, hypothenar spaces, or reach the dorsum of the hand via the lumbrical canals, forming massive necroses. The pathology requires immediate surgical treatment.

Class and exam questions

What else to study on this topic

• Topographic anatomy of the synovial sheaths of the 1st and 5th digits
• Lumbrical canals as pathways of infection migration
• Features of surgical access in U-shaped phlegmons
• Differential diagnosis of subcutaneous and subfascial phlegmons of the dorsal hand
• Topography of the oval gaps of the aponeurosis

Other topics from the section "CHAPTER 11. SURGICAL INFECTION (PURULENT-INFLAMMATORY DISEASES)"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.