Felons of the fingers
Acute purulent inflammation of the finger tissues is called a felon (panaricium). V.K. Gostishchev's classification includes 12 forms, which depend on the depth of infection penetration.
Superficial forms and disorders of the nail apparatus include:
- Subungual felon (panaricium subunguale) — accumulation of pus beneath the nail plate.
- Paronychia (paronychia) — inflammatory process in the perionychium. May be complicated by the breakthrough of pus under the nail (marginal or deeper).
Deep forms involve the subcutaneous tissue, tendons, and bones:
- Subcutaneous felon (panaricium subcutaneum) — may be localized on the distal, middle, or proximal phalanx.
- Tendinous felon (panaricium tendinosum) — purulent tenosynovitis of the flexors.
- Articular (panaricium articulare) and bone-joint felon — involvement of the interphalangeal joints and articular ends of the phalanges.
- Bone felon (panaricium osseum) — osteomyelitis of the phalanx.
- Pandactylitis (pandactylitis) — purulent melting of absolutely all tissues of the finger.
Surgical treatment of nail disorders
In paronychia, Kanavel's operation is used. A transverse incision of the skin fold (eponychium) and two parallel incisions in the proximal direction are made. The resulting U-shaped flap is turned back proximally, after which the margin (root) of the nail detached by pus is excised.
In subungual felon (hematoma suppuration), trepanation is performed — drilling with a burr or layer-by-layer excision of a hole in the nail plate with a scalpel for pus outflow.
If the cause was a splinter that penetrated under the free edge, wedge excision is performed. The area of the nail covering the abscess and splinter is excised in a wedge shape, simultaneously removing the foreign body.
Purulent tenosynovitis and tendobursitis
Access routes for inflammation of the synovial sheaths of the 2nd, 3rd, and 4th digits are made on the lateral surfaces of the proximal and middle phalanges, anterior to the bone. The synovial sheaths are opened, guided by the glistening tendons.
Forbidden zones for incisions: palmar cutaneous interphalangeal creases. Beneath them lie the annular ligaments of the osteofibrous canals. Their damage leads to dislocation of the flexor tendon from the wound, its desiccation, and loss of finger function.
Drainage through lateral incisions is performed strictly anterior to the tendon. Placement posterior to the tendon damages its mesotendon, causing necrosis. Additionally, incisions are made on the palm over the blind ends of the synovial sheaths.
Tenosynovitis of the 1st and 5th digits is called tendobursitis (radial and ulnar). Their feature is the need to open the Pirogov-Parona space in the lower third of the forearm, where the proximal blind recesses of the radial and ulnar synovial bursae are located.
Phlegmons of the hand
Purulent inflammatory processes of the hand are divided into cutaneous abscesses (collar-button abscess), thenar and hypothenar phlegmons, as well as subcutaneous and subaponeurotic phlegmons of the palm and dorsum of the hand.
- Subaponeurotic phlegmon of the middle fascial space of the palm: Opened according to the Voyno-Yasenetsky–Piku method. Two longitudinal incisions are used: medial (internal to the tendon of the flexor pollicis longus) and lateral (over the hypothenar eminence). Intermuscular septa are blunted. Drains are passed completely through both incisions. After surgery, the hand is immobilized in a semi-flexed position on a splint.
- Subcutaneous phlegmon of the dorsum of the hand: Incised directly through the center of fluctuation.
- Subaponeurotic phlegmon of the dorsum of the hand: Requires two incisions — over the 2nd and 5th metacarpal bones, since the deep fascia attaches to them. Drainage tubes are placed in both incisions.
Briefly: answers to topical questions
Where is the Pirogov-Parona fascial space located and what are its boundaries?
The Pirogov-Parona fascial space is the deep part of the anterior fascial compartment of the forearm, located between the muscles of the third and fourth layers. It has the following anatomical boundaries:
- Anteriorly — posterior (deep) surface of the muscles of the third layer (m. flexor pollicis longus and m. flexor digitorum profundus).
- Posteriorly — interosseous membrane (membrana interossea) and m. pronator quadratus along with its fascia.
- Laterally — anterior radial intermuscular septum.
- Medially — deep fascia of the forearm fused with the ulna.
- Superiorly — attachment site of m. flexor pollicis longus and m. flexor digitorum profundus to the interosseous membrane.
- Inferiorly — lower wall is absent, the space transitions directly into the carpal tunnel (canalis carpi).
What are the anatomical boundaries of the middle fascial space of the palm?
The middle palmar space (Compartimentum palmaris medius) is the central compartment of the hand, bounded by four walls. Its anatomical boundaries include:
- Anterior wall — formed by the palmar aponeurosis (aponeurosis palmaris).
- Posterior wall — formed by the deep fascia covering the palmar interosseous muscles and the horizontal part of the lateral intermuscular septum.
- Lateral wall — formed by the vertical part of the lateral intermuscular septum.
- Medial wall — formed by the medial intermuscular septum.
The flexor tendons further divide this space into two compartments: subaponeurotic and subtendinous.
What is a U-shaped (crossed) phlegmon of the hand and how does it develop?
Crossed, or U-shaped, phlegmon is the most severe form of purulent inflammation of the hand. It occurs as a consequence of purulent tenosynovitis of the 1st or 5th digit when the purulent exudate spreads to the radial or ulnar synovial bursa. In the proximal part of the hand, these bursae lie close to each other, and in 10% of cases they communicate. In virulent infection or inadequate treatment, pus melts the walls of the bursae and penetrates from the affected to the healthy one, forming a purulent "cross". A severe complication of this process is the breakthrough of pus into the deep Pirogov-Parona fascial space of the forearm.
What types of hand phlegmons are distinguished depending on localization?
Depending on the anatomical location of the purulent focus, the following types of hand phlegmons are distinguished:
- Subcutaneous phlegmon — localized on the palmar surface.
- Palmar supratendinous phlegmon — located between the aponeurosis and tendons (supra-aponeurotic).
- Subtendinous phlegmon — located deeper than the flexor tendons.
- Thenar phlegmon (thenar) — involves the thenar eminence.
- Hypothenar phlegmon (hypothenar) — involves the hypothenar eminence.
- Phlegmon of the midpalmar space — localized in the central part of the palm.
- Interdigital (commissural) phlegmon — located in the distal part of the palm.
- Subcutaneous phlegmon of the dorsum of the hand — superficial lesion of the dorsal side.
- Subfascial (subaponeurotic) phlegmon of the dorsum of the hand — deep lesion of the hand dorsum.
Class and exam questions
Why is it forbidden to make incisions at the palmar interphalangeal creases in purulent tenosynovitis?
Annular ligaments retaining the tendon are located in these zones. Their incision will lead to dislocation of the tendon from the wound, its desiccation, and complete loss of finger flexion function.
How to properly place a drain during the opening of the synovial sheath on a finger?
The drain must be passed strictly anterior to the tendon. If passed posteriorly, the mesotendon supplying it will be damaged, leading to necrosis.
Why are incisions made on the forearm in tenobursitis of the I and V digits?
The synovial sheaths of the I and V digits (radial and ulnar) extend into the forearm, forming blind pouches in the deep fascial space of Pirogov-Parona, which must be drained.
What is the essence of the Voyno-Yasenetsky — Piku approach?
This is the opening of a deep phlegmon of the midpalmar space using two incisions (near the thenar and hypothenar eminences) with blunt disruption of the intermuscular septa for through-and-through drainage.
What else to study on this topic
- Anatomy of the osseofibrous canals of the fingers and their ligamentous apparatus
- Structure and topography of the radial and ulnar synovial sheaths
- Boundaries and contents of the Pirogov-Parona fascial space
- Topographic anatomy of the fascial compartments of the palm (thenar, midpalmar, hypothenar)
- Principles of splinting and immobilization of the hand in the postoperative period
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