Acute purulent diseases of fingers

(Panaricium)

The problem of panaricium treatment, despite of a long-term history, remains actual not only owing to frequency of a pathology (in Ukraine panaricium is annually observed at 1 % of the population). In practice of surgeons the tradition of long application of conservative methods of treatment, performance inadequate and vicious operative cutting, providing only evacuation of pus without necessary necrectomy until now kept. In some cases purulent process stopped also, a wound heals, but the finger as functioning anatomic structure becomes unsuitable owing to cicatricial contracture and infringements innervations.

Panaricium - is acute purulent inflammation of finger tissue of a hand or less often than a foot. On the skin of palm surfaces of a finger connected with palm aponeurosis dense tendor between which there is a congestion of a fatty tissue (fig. 3 - 4). Inflammatory defeats of a skin or traumas the inflammation quickly distributed to a campaign connecting tissues to deep tissue: sinews, bone formations joints. Besides the congestion exudates in the closed cavities between connecting tissues crosspieces leads to infringement of blood circulation for the account compression having vessels and to fast development necrosis tissue. Panaricium results from fine traumas palm a surface of fingers in a life, on manufacture is more often, less often it grows out breakings agnail or micro traumas at manicure. Contribute to occurrence and long current panaricium diabetes, chronic infringements of blood circulation. The activator of disease is banal purulent microorganisms (staphylococci, streptococci). As an entrance gate of an infection, fine damages of a skin (a graze, a crack, a scratch) serve. Frequently the reason of an inflammation is alien bodies (splinters, a metal shaving)

The anatomy of fingers and is submitted to a brush on fig. 1-4.

 

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 Fig.1 Superficial vessels and nerves of a brush.

1 - ramus palmaris n. mediani; 2 - . ulnaris; 3 - lig. carpi volare; 4 - ramus palmaris manus n. ulnaris; 5 - ramus dorsalis manus n. u1naris; 6 - os pisiforme; 7 - m. palmaris brevis; 8 - m. abductor digiti minimi; 9 - aponeurosis pa1maris; 10 - nn. digitales pa1mares proprii; 11 - foramina comissuralia; 12 - . digitales palmares ri;      13 - pars anularis vaginae fibrosae; 14 - pars cruciformis vaginae fibrosae; 15 - a. digitales palmares communes; 16 - rami musculares . mediani; 17 - m. f1exor lliis brevis; 18 - m. abductor pollicis brevis; 19 - ramus super ficialis . radialis; 20 - v. cephalica.

Rice 2 Topography of a deep arterial arch

1 - . pronator quadratus; 2 - . et A. ulnaris; 3 - . f1exor carpi ulnaris; 4 - os pisiforme; 5 - ramus profundus n. ulnaris; 6 - ramus palmaris profundus . ulnaris; 7 - arcus palmaris profundus; 8 - . et aa. digitales palmares mmunes; 9 - . et n. digitalis palmaris proprius; 10 - mesotenon; 11 - vagina synovialis digiti minimi; 12 - . et nn. digitales palmares proprii; 13 - tendines . f1exoris digitorum superficialis; 14 - tendines . f1exoris digitorum profundi; 15 - nn. lumbricales; 16 - . metacarpea lmaris; 17 - aponeurosis palmaris.

 

 

Fig. 3 - 4. An anatomic structure of a nail phalanx. Arteries are shown, Nerves, trabecules, bone.

 

Classification. A. Superficial classification of the form - paronichium, skin, hypodermic; B. Deep form - bone, articulate, tendor pandactilitis.

General characteristic and clinical picture. Distinguish some forms panaricium. However, their clinical displays in many respects coincide. First, patients are disturbed with a hypostasis and reddening of the struck site of a finger. The body temperature can implicate at heavy defeats, the common condition considerably worsens. For panaricium pulling, intensive, constant pains are characteristic.

It is necessary to note, that in connection with prominent features of anatomy of a brush at localization of an abscess on palm surfaces of a finger, the hypostasis and reddening will be more expressed on its back surface.

Intraskin panaricium. Pus settles down in the uppermost layers of a skin, stratifying it. Thus, the bubble filled purulent or blood with a liquid formed.

Hypodermic panaricium. At close examination the pressure of tissue, a smoothness located near to interphalanx plica pay to itself attention. Reddening soft.

Paronichium - an inflammation of paranail platen, accompanying with its painful swelling and reddening of surrounding tissue. At survey it is marked hang struck paranail platen above a nail plate. In some cases, pus can penetrate under a nail. Thus, exudates appears through exfoliation part of a nail.

Subneil panaricium - is characterized by a congestion of pus under a nail plate. At developed process pus is seen under all nail or less than one of its edges.

Articulate panaricium - arises more often after wound of a back surface of a finger above a joint. The pain has intensive character, skin sulcus in the field of a joint smooth out, the skin reddens; because of a hypostasis the finger gets fusiform. Attempt of bending of a finger leads to acute amplification of pains. In the started cases the joint collapses, the fistula can formed. Pains thus deplica a little, but functions of a finger are not restored. There is a unnatural mobility, sensation of a crunch in the field of a sick joint.

Bone panaricium - develops or at transition of an inflammation from soft tissue, or at direct wound of a bone (an injection a sewing needle, a shaving, a fish bone). In case of transition of an inflammation from soft tissue surrounding a bone, after the period of imaginary improvement of full recovery does not come. The pain has constant whining character, there is a fistula with poor purulent separated. A finger gradually all make thicker, functions of it are completely lost.

Tendor panaricium - purulent process of hypodermic panaricium at absence of high-grade treatment can be distributed to sinews fingers flexor. Significant deterioration of the common condition is marked. The pulsing, pulling pain is distributed on all fingers. Also on all length of a finger reddening a skin and a hypostasis is distributed. Interphalanx plica smooth out. The finger becomes similar to a sausage and is slightly bent. Such compelled position reduces a tension of a sinew and reduces a pain.

Pandactilitis - purulent inflammation of all finger tissues. Proceeds hardly, it is accompanied by a headache, a high body temperature. The nearest lymph nodes implicate. Pandactilitis can develop and owing to wound of a finger, but is more often the reason of it are untreated simple forms of panaricium. Development of pandactilitis the pain gets holding apart character. Blue-crimson color oedematose of finger. All tissue gradually becomes necrotic. From fistulas or postoperative wounds pus in small amounts flows. Touch up to a finger acute painfully. Attempt of movements attracts acute amplification are ill. The further development of pathological process leads to distribution of suppuration on a brush and further - on all finiteness.

First aid. Panaricium develops very quickly. At the initial stages when in the field of a finger there is a feeling of morbidity at movement or pressing, it is possible to try to stop process by reception of anti-inflammatory and antibacterial preparations, alternation of warm salt trays with vodka bandages. All attempts of self-treatment or conservative therapy should stop at occurrence of pulling constant pains. Address to the doctor! There is a trope determining terms of performance of operation: "If the patient has met a morning dawn, being tormented by pains in a finger up to an evening dawn it should be operated."

       Medical tactics and treatment of panaricium separate forms

Paronichium. Practical doctors quite often underestimate this pathology, including its frivolous. Meanwhile, at wrong treatment paronichium can get chronic current, delivering a great deal of trouble to the patient. The paronichium reason, as a rule, there are agnail, or disease develops after wound of a skin of the platen at manicure. There is a hypostasis, reddening paranail platen, intensive pains. Further appears exfoliate epidermis the platen pus, at territory of a nail plate pathological granulations acute to develop. Treatment is necessary for beginning as soon as possible. At occurrence of first attributes of an inflammation (reddening of a skin, a pain) it is necessary to bring the thin gauze strip moistened alcohol solution of chlorgexydinum under a skin paranail platen, exfoliate of nail plate in a zone of an inflammation.

 

 

  Fig. 5 Technique of operation of panaricium.

 

In some cases, it happens enough for knocking over of an inflammation within 2-3 days. Occurrence exfoliate of epidermis pus, it is necessary immediately accurately cut (instead of simply to pierce - as it is quite often wrongly made) exfoliate a site, to evacuate purulent exudates and to bandage with alcohol solution of chlorgexydinum, having brought under a skin of the platen the gauze strip moistened with this solution. In case of development between a leather paranail platen and a nail plate of pathological purulent granulations - surgical treatment is necessary. The section on a back surface of a nail phalanx is made, all carefully leave necrotic tissues, granulations, sometimes to have cut sprout zone of a nail plate. In the postoperative period the wound is conducted openly, bandages with ointment "Levomicol" are imposed.

 

Skin panaricium. Develops owing to a superficial micro trauma. Quite often skin panaricium it is accompanied expressed to the phenomena lymphangitis and lymphadenitis, that can disturb the patient more, than primary process. Treatment surgical - is made cut exfoliate of epidermis, as a rule thus it is not required to anesthesia. It is evacuated purulent exudates and then it is necessary to examine carefully erosive surface do not pass panaricium as "cuff link" (when purulent process by a narrow course is distributed in hypodermic cellular tissue). The inflammatory phenomena stopped during 5 - 10 days depending on prevalence of process (fig. 5).

 

Subneil panaricium. Disease arises as consequence paronichium; at direct entering an infection under a nail plate (an injection a needle, a nail); or is complication subneil hematomas (frequently after a trauma of a finger a door). Prophylaxis of diseases - competent treatment paronichium and early evacuation of subneil hematomas after trauma. Local exfoliate a nail plate pus (less than 1/3 its common areas) are allowable to execute a resection of a nail only on the changed site. In a case of more extensive defeat, it is necessary to delete completely a nail plate, keeping sprout zone of a nail (if it is possible) (fig. 5). As a rule erosive surface nail a box has well epithelisation on the average through 10 - 15 days after operation.

 

 Hypodermic panaricium. Disease develops at hit of an infection in hypodermic cellular tissue of finger with the further development of a purulent inflammation. As a rule, investigation of a micro trauma - an injection, a cut, a splinter etc. First the moderate hypostasis and reddening of a finger skin is marked, further the inflammatory phenomena progress, pains get pulsing character, become very intensive. Treatment - surgical (fig. 5, 6).

         

Rice 6 Surgical treatment hypodermic panaricium.

On a nail phalanx of a finger it is made "sticklike" cut, on average and basic phalanxes the section on a lateral surface is done. Skin-hypodermic rags part and is carried out careful necrectomy. Characteristic mistake of hypodermic panaricium treatment is the default necrectomy. Very much frequently surgeons are limited only to a cut (section) above the center of an inflammation that leads to time improvement of state of health of the patient, and purulent - destructive process is distributed more deeply to sinews and a bone basis of a finger. The ambassador necrectomy the formed cavity is carried out by a gauze strip with Levomicolum so that edges of a wound have been developed. Further, daily change of bandages is made. At adequately executed necrectomy in the postoperative period in a wound should not be purulent separated. Presence of pus within 2-3 days after operation serves as the indication to repeated necrectomy. After clarification of a cavity in hypodermic cellular tissue edges of a wound adapt an adhesive plaster, it is possible to impose secondary seams on a drainage.

 

Tendor panaricium. One of the heaviest kinds is of panaricium. Arises complex purulent tendovaginites symptoms. Disease develops or owing to primary entering an infection in tendor vagina tendons (a cut, an injection, etc.), or as progressing of hypodermic process at inadequate treatment of the last. At development of a purulent infection in tendor vagina the clinical picture happens enough bright - the patient is disturbed with the expressed pains on a course of sinews, any movements are extremely painful. The surgical help has to be rendered as soon as possible as sinews quickly perish in conditions of surrounding purulent process. Operation made under bearer anesthesia (fig. 7).

         

Rice 7 Bearer anesthesia in surgical treatment panaricium.

Absence of a purulent inflammation in hypodermic cellular tissue of a finger (and it happens when the infection gets directly in environments of a sinew at an injection) is allowable to execute surgical processing a primary wound, having opened tendor vagina in this zone, and to make a cut for projections vaginas of sinews tendons also with opening the last. The vagina is carefully washed out by antiseptics from two sides and made drainaging of the punched polymeric tubule (fig. 8).

                        

  Rice 8 Treatment tendor panaricium

 In a case when the purulent inflammation hypodermic cellular tissue takes place is made a cut on a lateral surface of a finger with arc-like continuation on a palm in a projection "blind volvulus" vaginas of sinews tendons. Skin-hypodermic rag of the palm is dissecting from subject tissue, is made careful necrectomy in cellular tissue, opened and sanified tendor vagina. At revealing necrosis sinews the last cut within the limits of healthy tissue. Operation comes to the end with performance of a wound by a gauze strip with Levomicolum so that edges of a wound have been as much as possible developed, that will allow to supervise a condition of sinews (if they have been kept) on the further bandaging. Further, in process of clarification of a wound, edge adapts plaster strips or secondary seams are imposed. At confidence of completeness of performance necrectomy it is possible to stitch of operational wound after imposing drainaging-washing system (system of the punched polymeric tubules, drainaging the formed cavities).

 

Articulate panaricium. Develops at direct hit of an infection in a cavity of a joint (of wound), or as investigation of long purulent process in soft tissue of a finger above a joint. Quite often surgeons at processings purulent wounds in a projection of joints of a finger not made inspection a capsule of a joint, and damage of last are looked through, and the purulent arthritis is diagnosed later when the characteristic clinical picture is already shown. For articulate panaricium, it is typical spindle-like expansion of a finger in projections of an interphalanx joint, acute restriction of movements in a joint, morbidity of palpation and movements, occurrence of pathological mobility and crepitation in a joint (fig. 9).

Rice 9 Articulate panaricium. Bone changes.

Treatment only surgical - is made arthrotomy, careful sanitation of a cavity of a joint by antiseptics, then a cavity of a joint draining by the punched polymeric tubule. It is necessary to aspire to close necessarily a wound above a cavity of a joint. The basic moment - after operation it should be carried out distraction with the purpose of deplica in intra articulate pressure and prevention of the further destruction the articulate ends. Distraction it is made or imposing distraction the device, or extension of a finger for a nail phalanx, gypsum by Kirshner. Distraction by Kirshner stops in process of knocking over of the inflammatory phenomena (7-10 days), and distraction device is kept on a finger of 1-1,5 months, in it begin development of movements in a joint.

 

Bone panaricium. Develops, as a rule, or at direct hit of an infection in a bone tissue (at infected open crises), or at distribution of purulent process on a bone with surrounding soft tissues, at wrong treatment of more superficial purulent processes on a finger (fig. 10).

      

Fig. 10. Ways of distribution of pus with development of deep forms panaricium.

Very quickly the infection is distributed on crest nail phalanx at development of purulent process on a top of a finger. If in this zone the purulent inflammation kept within 6-7 days, it is possible to count, that the bone is involved in process, even at absence of radiological changes. In general, it is necessary to remember, that the radiological picture always "is late" in comparison with real changes in tissue a little. Despite of this, radiological inspection - an obligatory component in diagnostics bone panaricium.

Surgical treatment. The cut providing a good exposition for audit of the struck bone is made. The ambassador necrectomy in soft tissue it is carried out sequestrectomy in a bone basis by acute bone spoon - the struck sites are gently scraped out. All viable sites of a bone are kept. If operation is carried out in conditions of the acute inflammatory phenomena in soft tissue of a finger, the operational wound is conducted openly (bandaging with Levomicolum). In case of performance of operation at the abating inflammatory phenomena (at long terms of disease, formation of fistulas), after performance radical sequestrectomy, if it is possible, stitching of operational wound with leaving of the punched polymeric drainages in the formed cavities of a finger. Tubules are daily washed out on bandaging and leave for 5-7 day.

 

Bone-articulate panaricium. Develops, as a rule, owing to progressing articulate panaricium and inadequate treatment of the last. At this disease there is an involving in purulent process of the articulate ends of interphalanx joints to their development destruction. Cardinal difference of pandactilitis is preservation of sinews surrounding a joint (tendons and extensor). Treatment surgical.

 

Fig. 11. Bone-articulate panaricium. A general view of the struck finger and treatment.

More often it is made bayonet like cut on rear of a finger in projections of a corresponding joint or a cut on a lateral surface of a finger (when it is impossible to exclude completely distribution of purulent process on palm surface of a finger). The sinew extensor where it is possible to find out the defect conducting in a cavity of a joint is exposed. The sinew is dissected above a joint in a longitudinal direction; fibers are moved apart, than the good review of a cavity of a joint is provided. Removal purulent exudates, pathological purulent granulations from a cavity of a joint, washing by antiseptics is made. Then acute spoon it is gently carried out sequestrectomy in the struck bone sites. After final sanitation of a cavity of a joint last drainaging in a cross-section direction the punched polymeric tubule that ends are deduced through separate puncture. Integrity of a sinew extensor of atraumatic string 6/0 is restored and skin seams are imposed. An extensive resection of the articulate ends when between them than 4 mm special decompression are created diastases more is not required. In a case when pressure of the articulate ends against each other is kept, it is necessary decompression in a joint by imposing distraction device, or due to extension for a nail phalanx (sees articulate panaricium).

 

Pandactilitis. This heaviest purulent defeat of a finger of a brush. Include defeat of a leather, hypodermic cellular tissue, tendor structures, a bone and (or) a joint (fig. 12).

 

 

Fig. 12. Pandactilitis. A general view of the struck finger and bone changes on the roentgenogram.

Until now in many sources, it is possible to find out recommendations to amputate a finger at pandactilitis. However, the present stage of development of medicine it is necessary to search for ways to preservation of anatomic integrity of a finger and its functional activity. Surgical access at this pathology should provide the good review of all struck structures. The cut is made on a lateral surface of a finger. If necessary audits of a "blind" volvulus vaginas zone of sinews tendons the cut on an arch precedes on a palm in a projection of the head corresponding bones. It is stupidly allocated palm neurovascular bunch of a finger then palm the skin-hypodermic rag exfoliates from sinews tendons. In the similar image operated a back rag. Both rags are developed, providing a good exposition. It is carried out careful necrectomy in all structures of a finger, by those principles, which are described at treatment hypodermic, tendor, articulate and bone-articulate panaricium. The drainage-washing system if necessary imposed, under indications in the postoperative period is carried out distraction in a joint by that or other method. In some cases in result necrectomy or owing to primary traumatic damages are formed extensive skin defects. As soon as possible, in process of clarification of wounds, it is necessary to close them skin plastic in order to prevent development destruction depth lying structures. At presence of granulations in a wound the preference should be given free plastic the split skin rag, at presence in a wound naked tendered bone structures - it is expedient not free plastic (that or a different way. The similar approach allows avoiding unjustified amputation of a finger in many cases.

                      

Phlegmons of a brush

 

Classification. Will allocate on localization the following kinds of phlegmons of a brush:

1. An intermanual phlegmon; 2. A phlegmon of tenar area; 3. A phlegmon of hypotenar area; 4. Overaponeurosis phlegmon median palm spaces; 5. Subaponeurosis phlegmon median palm spaces: ) superficial, b) deep; 5. A phlegmon of rear of a brush; 6. Cross (U-shaped) a phlegmon of a brush with defeat of Pirogov-Paron space; 7. Connecting phlegmons of brush.

Diffuse purulent defeat cellular tissue spaces of a brush. Depending on localization have characteristic symptoms. Infringement of brush function; local rise in temperature; morbidity concern to local attributes of inflammatory process a hypostasis and hyperemia tissue at palpation. The degree of expressiveness of the specified symptoms is various and depends on extensiveness of inflammatory process, virulence activator, protective reaction of an organism, it immunobiologic reactance, etc.

 

     Phlegmons of an eminence of the first finger are accompanied by a acute hypostasis tenar and beam edge of a back surface of a brush. An acute pain at palpation, a pressure of tissue, restriction of mobility edematous tissues of tenar, a smoothness of palm skin plica - characteristic symptoms of an inflammation fatty cellular tissue the tenor (fig. 13).

         

Fig. 13. A phlegmon of an eminence of the first finger.

 

Phlegmons of hypotenar are shown by moderately expressed hypostasis, hyperemia and a pressure of tissue, morbidity of palpation. Movements of the fifth finger lead to amplification of a pain.

 

Commissural phlegmon. An entrance gate of an infection is cracks rough callosity skin in region of metacarpus-phalanx joints of palm. From here and other name - corn abscesses, "naming". The inflammatory center form, as a rule, in commissural spaces II-V of fingers (fig. 14).

          

Fig. 14. Commissural phlegmon.

Phlegmons are accompanied by significant pains, hypostasis distal parts of both surfaces of a brush. Fingers in the neighborhood with the purulent center are little bit dissolved and bent in interphalanx joints. Extension is painful because of a tension inflamed palm aponeurosis. Probably direct distribution of pus through oval cracks aponeurosis with palm on a back surface of a brush, and involving of a sinew deep tendon of finger that is taking place in immediate proximity from the purulent center. Distribution of an infection can occur and in proximal direction on channels vermiform muscles. In these cases, the inflammation joins the basic center median palm spaces.

 

     The phlegmon of median palm space is located between palm aponeurosis and fascia, covering tendons tendons fingers - subaponeurotic phlegmon. It is clinically accompanied by the expressed purulent intoxication, headaches, high temperature. The central part of a palm erupt, palm plica fingers half-bent smoothed, and attempt of active or passive movements in them is accompanied by acute pain.

Cross or U like phlegmon. It represents joint defeat synovial bags of a palm ulnar and beam. Disease is investigation purulent tendovaginites of I or V a finger. Under certain conditions pus is distributed on synovial bag beam or ulnar sides of brush, causing their inflammation. These phlegmons are accompanied expressed intoxication, a high body temperature, the general weakness, a headache. A brush is edematous, blue- crimson, fingers half-bent, movements in them because of a pain are impossible. During palpation the greatest pain in a zone of sinews tendons I and V fingers in proximal parts of brush.

 

The hypodermic phlegmon of a back surface of a brush causes a hypostasis and hyperemia without precise borders hypodermic cellular tissue and skin on rear of brush. Accompanied a pain, rise in temperature, infringement of function of a brush and fingers.

 

Subaponeurotic phlegmons of a back surface of a brush are shown dense, painful infiltrate, a hypostasis and hyperemia of skin on rear of brush. These phlegmons, as a rule, are secondary in relation to inflammatory diseases palm surfaces of brush.

 

Furuncle, carbuncle of brushes. Local displays are typical for all localizations of furuncles and carbuncle. Functional activity of a brush is always broken.

Usually the phlegmon of a brush develops again. The inflammatory center is formed, as a rule, in commissural spaces II - IV fingers. Apertures palm aponeurosis promotes distribution of an infection from superficial abscesses deep into.

 

The general principles of brush phlegmons treatment:

Treatment of patients with phlegmons of a brush should be carried out in a surgical hospital.

It is necessary to establish maximum precisely what cellular tissue space of a brush is struck, that is important for a choice of adequate access.

Operative intervention should be early and be carried out at strict observance of aseptic rules.

Optimum anesthesia and full draining of blood is necessary for a brush.

Necrectomy and drainaging of abscess - the major moments of operation.

Adequate antibiotic therapy in view of sensitivity of microflora.

Application of various kinds of local therapy after operative intervention, depending on localization of the center of an inflammation.

Immobilization.

Rehabilitation of patients, preventive maintenance of complications.

 

Mistakes of panaricium and brush phlegmons treatment

The most typical mistake of polyclinic surgeons is refusal of primary surgical processing casual wounds of a brush. The purulent wound necessarily should be exposed to surgical processing - under conductor anesthesia is carried out necrectomy with audit of all damaged structures. Special attention a wound on a back surface of fingers and a brush in a projection of interphalanx and metacarpo-phalanx joints demand.

 

Mistakes of diagnostics. For an establishment of the correct diagnosis at a level of a polyclinic it is not required the expensive equipment or performance of complex analysiss. It is quite enough to collect the anamnesis, closely to examine the patient and to execute the roentgenogram of brush. The wrong diagnosis of the form panaricium or phlegmons of a brush entails the inadequate operative manual and finally can lead to progressing of disease. We consider necessary to allocate a number of prominent aspects, which will help to put the correct diagnosis.

          The purulent inflammation of palm and back surfaces of fingers and a brush proceeds differently owing to a various structure hypodermic cellular tissue. On rear of a brush distribution, purulent exudates occur on a plane whereas on palm surfaces the zone necrosis is quickly distributed in depth of tissue, involving in destructive process tendor and bone structures. The structure of cellular tissue palm surfaces on type "hundredth" makes unpromising attempts of conservative treatment of purulent wounds of this localization without good necrectomy whereas on rear of a brush conservative actions in some cases can be justified.

            At long purulent separated from a wound distal a department of a nail phalanx of a finger (within five and more days) it is necessary to take into account an opportunity of development bone panaricium with defeat comb of nail phalanx, even at a negative radiological picture. In this zone, process is very quickly distributed up to a bone, and changes on the roentgenogram, as a rule, are late and are shown on 10-14 day of disease.

          Localization of wounds and the inflammatory phenomena on fingers in a projection tendorvaginas tendons it is necessary to check necessarily presence of morbidity at palpation button probe in a projection blind volvulus tendorvaginas even at constant integuments in this area. The expressed morbidity on a course of sinews tendons, caused by a congestion inflammatory exudates, allows suspecting development tendor panaricium, and at this pathology, the operative manual should be executed as soon as possible in order to prevent development necrosis sinews.

           Occurrence of pathological lateral mobility and crepitation in an interphalanx joint, is especial at localization of wounds in a projection of a joint, allows diagnosing with the big confidence articulate or bone-articulate panaricium.

            Wounds in a projection of metacarpus-phalanx joints demand careful audit as will frequently penetrate into a cavity of a joint that remains unrecognized at survey. Further when the destructive centers in jointed bone structures develop, function of a joint and a finger happen is irreversible is lost.

 

             Mistakes at performance of anesthesia. One of frequently met mistakes is inadequate anesthesia. Patients long remember feeling of a pain during operation and further with fear for recurrence of the sensations wait, that in some cases serves as an occasion for refusal of operation.

             Besides the method of anesthesia not always gets out correctly. Puss inflammatory diseases of fingers and a brush local infiltrative anesthesia should not be applied, as not providing adequate anesthesia. Performance bearer anesthesia at various levels (at a level metacarpal bones, radio-carpal joint, to the top third of forearm, axillaries forearm), and the place of an injection anesthetics should be located outside of a zone of an inflammation. We count categorically contra-indicated repeated introduction local anesthetic solutions with antibiotics in inflamed edematous tissue as medical manipulation as this procedure leads to the further in plica of interstitial pressure with the subsequent necrosis of soft tissue.

 

         Mistakes of operational access choice. The inadmissible recurring parallel cuts on palm surfaces of one phalanx of a finger. Thus skin "bridges" becomes necrotic, cuts do not provide adequate outflow exudates, and the most important, similar wounds complicate the further performance radical necrectomy.

        Access at operation concerning puss inflammatory diseases of fingers and a brush should get out depending on presence or absence of wounds. At already available damages of integuments on back or palm defect of a skin it is necessary for a surface economically section to model as Z-shaped on fingers and arch like or S-shaped on brush. At wounds on lateral surfaces of a finger the section extends on neutral lines. At the intact integuments, access on fingers should be carried out on lateral surfaces or is Z-shaped from a back surface. Palm surface of a finger is necessary for sparing as much as possible. It is categorically unacceptable long longitudinal sections on palm and to back surfaces as fingers, and a brush as further it leads to expressed cicatricial contracture and to acute frustration of sensitivity.

          Mistakes of processing the purulent center. The roughest and, unfortunately, most frequently a met mistake is performance of a skin section without cutting of necrotic tissue in hope for the further independent tearing away necrosis on bandaging. Such tactics is vicious, as after opening pressure in tissue pains are reduced, deplica, that by the doctor and the patient is regarded as positive dynamics, and at this time purulent - destructive process progresses in depth of tissue, amazing the important anatomic formations. Further radical necrectomy can be poured out in amputation of a finger or a phalanx. Necrectomy - an obligatory condition of surgical treatment panaricium and phlegmons of a brush. Any removal impractical tissue on fingers and brushes should be carried out at full drain of blood that is achieved by imposing rubber tourniquet on the basis of a finger or a cuff from a ton meter on a forearm. Use of rubber bandage on a forearm which is imposed on a spiral is allowable also. The manipulation in tissue "blindly" can lead to damage of a neurovascular bunch and tendor structures with all following negative consequences.

 

Mistakes at end of operation and conducting the postoperative period. Necrectomy on fingers and a brush comes to the end with sanitation of a cavity by solutions of antiseptic tanks and friable performance of a wound by gauze strips or napkins with ointments on a water-soluble basis (Levosin, Levomekol, etc.). Absence of attributes of deterioration of local process the strip from a wound leaves for the second - third day. The condition of a cavity is visually estimated. In case of adequate necrectomy walls of a cavity in these terms already pure, appear the granulations, separated of a wound poor, serous-purulent. If a wound with plentiful purulent separated, with necrotic tissue, peryfocal inflammation without the tendency to knocking over, it is necessary to solve the problem about repeated necrectomy.