Surgical treatment of purulent hand diseases

Topographical anatomy and the "forbidden zone"

The success of hand surgery largely depends on the understanding of topographical anatomy, primarily the location of the median nerve (n. medianus). It is critically important to know the topography of its muscular branches so as not to damage them during the incision and to preserve the function of the thenar muscles (thenar).

Of particular surgical significance is the so-called "forbidden zone"—an area where the first and most important muscular branch of the median nerve is located. In terms of projection, this zone corresponds to the proximal edge of the skin crease separating the thenar area from the middle palmar part of the hand. The boundaries of this zone are described in detail in the classical works of V.V. Kovanov and A.A. Travin and are defined between three conventional lines.

Choice of anesthesia and instruments

The method of pain relief directly depends on the form and extent of the purulent process:

• In localized forms (subcutaneous felon of the distal and middle phalanges, subungual felon, paronychia), the method of choice is Oberst-Lukashevich conduction anesthesia. A prerequisite for its execution is the application of a tourniquet at the base of the finger. This allows for a completely bloodless operative field, improves the visualization of structures, and enables thorough removal of all necrotic tissues.
• In severe forms (tendon felon, pandactylitis, deep phlegmons), intravenous local (regional) anesthesia is used.
• In widespread processes (severe hand phlegmons, phlegmon of Pirogov's space), full general intravenous anesthesia is indicated.

For operations on the fingers and hand, it is strongly recommended to use ophthalmic instruments (small scalpels, pointed scissors). The advantages of microsurgical instruments are obvious: they allow for adequate and precise incisions, convenient manipulation in an extremely small wound space, delicate handling of viable tissues, and at the same time complete excision of necrotic masses.

Surgical tactics: incisions and drainage

Surgical treatment consists of making incisions taking into account anatomical features and subsequent adequate drainage. Depending on the extent of the purulent process, linear unilateral or bilateral lateral incisions are used.

Any surgery for a purulent disease of the hand must end with drainage, except for the three most superficial forms:

1. Cutaneous felon.
2. Subungual felon.
3. Cutaneous abscess of the palm.

In all other cases, a fenestrated rubber tube is used. Its placement provides the possibility of through-and-through irrigation drainage—regular flushing of the purulent cavity with antiseptic solutions or proteolytic enzymes.

The clinical effect of such drainage includes:

• The fastest possible removal of purulent exudate from the wound.
• Significant reduction of pain syndrome in the postoperative period.
• Acceleration of necrotic tissue rejection processes.
• An overall reduction in wound healing and rehabilitation times.

Treatment of deep phlegmons and the edema assessment rule

In deep hand phlegmons, surgical tactics are more complex: drainage (through-and-through irrigation) is often carried out via drains brought out through specially created additional incisions.

The most important rule of purulent hand surgery is the correct clinical evaluation of dorsal edema. It should be remembered that in phlegmons localized on the palm, pronounced edema is always observed on the dorsum of the hand. Most often, this is collateral edema containing no pus.

Surgical rule: if the edema on the dorsum of the hand is pronounced, an incision should categorically not be made there until the likelihood of suppuration on the fingers and palmar surface is completely ruled out.

Three signs indicate the transition of collateral edema into true suppuration:

1. Body temperature does not decrease even after adequate opening of the abscess on the palm or fingers.
2. The edema on the dorsal surface becomes denser to the touch.
3. The skin over the edematous area turns red (hyperemia).

Class and exam questions

What else to study on this topic

• Exact anatomical boundaries of the "forbidden zone" according to V.V. Kovanov and A.A. Travin.
• Surgical anatomy and pathways of pus spread into Pirogov's space.
• Technique of Oberst-Lukashevich conduction anesthesia.
• Features of surgical tactics in pandactylitis and tendon felon.
• Choice of antiseptic solutions and proteolytic enzymes for through-and-through irrigation drainage.

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

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