Operative surgery of the hand

Classification of purulent hand diseases

Purulent-inflammatory processes on the upper extremity require precise topical diagnostics. Felons are classified depending on the depth of tissue involvement. The following main types of inflammation are distinguished:

• Cutaneous and subcutaneous felon (the latter may present as a "shirt-stud" abscess, where the abscess takes an hourglass shape).
• Tendon felon (acute tenosynovitis).
• Articular and osseous felon (the osseous form is often accompanied by sequestration of the middle phalanx diaphysis or the distal phalanx).
• Pandactylitis — the most severe condition, representing total purulent inflammation of all tissues of the finger.

General principles of surgical treatment

Conservative therapy for purulent hand diseases takes a back seat. The surgical method is the primary treatment approach. The main task of the operating surgeon is to create adequate outflow of purulent exudate (drainage).

A properly performed operation provides several critically important effects. First, interstitial pressure is instantly relieved, leading to a significant reduction in pain syndrome and swelling. Second, decompression restores impaired microcirculation in the tissues, which is essential to salvage hand structures and efficiently deliver antibacterial drugs directly to the focus of purulent inflammation.

Operations on the distal phalanx

The subcutaneous tissue of the distal (nail) phalanx has an important anatomical feature: it has a pronounced cellular structure. This is due to the presence of dense connective tissue septa running directly from the skin to the bone.

For the surgical treatment of subcutaneous felon in this area, a hockey-stick incision is used:

1. The scalpel is inserted from the lateral side of the phalanx, forming the so-called "hockey-stick hook".
2. The incision is made in the frontal plane toward the interphalangeal joint.
3. The most critical step of the intervention is the mandatory division of all connective tissue septa running from the skin to the bone. This is necessary for the complete destruction of purulent cells and evacuation of the exudate.

The advantage of this approach is the formation of a thin elastic scar on the lateral surface (the "handle of the hockey stick"), which does not impede normal hand function.

A gross error by the surgeon is making a midline incision on the palmar surface. It is completely ineffective, as it opens only a limited number of cells. Furthermore, such an incision leaves a scar on the working surface of the finger, which drastically reduces tactile sensitivity and limits flexion functions.

Surgery of the middle and proximal phalanges

Surgical treatment of subcutaneous felon in the region of the middle (second) and proximal (third) phalanges is performed according to Klapp's method. In these zones, surgeons use anterolateral approaches. The technique involves carefully incising the skin and the subcutaneous fat layer with a scalpel. Such anterolateral incisions provide adequate access to the infection site and ensure reliable drainage of the purulent cavity without damaging vital structures on the flexor surface of the fingers.

Interventions for purulent tenosynovitis

Purulent tenosynovitis is an acute purulent inflammation of the tendon synovial sheath. The pathogenesis of this disease is extremely dangerous: the accumulating exudate rapidly increases pressure within the confined space of the sheath and compresses the nourishing blood vessels. This quickly leads to severe ischemia and irreversible tendon necrosis. The goal of emergency surgery for tenosynovitis is the prompt opening of the affected synovial sheath and complete evacuation of the purulent contents to save the function of the tendon apparatus.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Operations on the dorsal surface of the distal (nail) phalanx.
• Operative surgery for hand phlegmons.
• Features of opening dorsal hand phlegmons.
• Diagrams of incisions according to V.K. Gostishchev.

Other topics in the "Upper Extremity" section

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