Bone felon – a purulent inflammation of bone structures of a finger. Can primary be (more rare) or secondary. Primary pathology is shown by the intensive pulling pain and a considerable hyperthermia in combination with hyperaemia, hypostasis and restriction of movements arising in several days after an injury of a finger or against the background of the remote purulent process. The secondary bone felon develops owing to spread of an infection at other forms of a disease, is followed subfebrilitety and the proceeding gnoyetecheniye. It is diagnosed on the basis of data of survey, a X-ray analysis, laboratory researches. Treatment quick – opening, a curettage, a bone resection. At considerable destruction of a bone amputation is shown.
Bone felon – a kind of a purulent inflammation of tissues of finger with damage of a bone (osteomyelitis). Is rather often found pathology, according to various data, makes from 37 to 60% in the general structure of pyoinflammatory processes in brush fingers. Primary osteomyelitis of a phalanx comes to light at only 5-10% of patients, at other patients the secondary inflammation of a bone is observed. In most cases (about 80%) the nail phalanx suffers. The disease is found in workers of productions with the increased probability of traumatizing and intensive pollution of hands the irritating substances more often – at tractor operators, mechanics, loaders, general workers and so forth. Pathology can be diagnosed in all age groups, prevalence of patients of middle age is noted.
Piogenny bacteria, usually – staphylococcus are an immediate cause of a purulent inflammation, their associations with other microorganisms, a sinegnoyny stick, colibacillus and kokkovy flora (enterokokk, streptococci) are more rare. Primary form develops at a hematogenic drift of an infection from the remote purulent centers and at paraossalny hematomas. Become the reasons of secondary purulent process:
- Hypodermic felon. Meets in the prevailing quantity of cases that is connected with the expressed local intoxication, the heavy violations of local blood circulation arising at an inflammation to finger cellulose, adjacent to a bone. Affects a disteel phalanx more often.
- Tendinous and articulate felon. Comes to light in the anamnesis less often than a hypodermic felon. Usually precedes purulent fusion of bones of the main and average phalanxes.
- Other forms of a felon. In some cases osteomyelitis of a disteel phalanx is found at a paronychia, a subnail or okolonogtevy felon, however such cases make an insignificant share in structure of incidence.
Because of high probability of development of a bone felon at a hypodermic form of a disease in special literature instructions on the fact that at the cellulose suppuration remaining within two and more weeks, osteomyelitis should be considered as a natural result of an inflammation of soft fabrics meet. To purulent damage of a bone at any etiology of process endocrine diseases, exhaustion, decrease in immunity of various genesis (are considered as the contributing factors at some diseases, chemical dependences, reception of hormonal means), the exchange frustration, trophic and microcirculator violations which are result of long impact of cold, vibration, moisture or the irritating substances on skin of hands.
At hematogenic spread of an infection gnoyerodny microbes get into bone substance through the feeding vessels. The periosteum and brain substance inflame, in a bone tissue sequesters are formed. At secondary pathology the inflammation from soft fabrics extends to a periosteum. Development of purulent process is promoted by the patologo-physiological conditions which are especially expressed at an inflammation of myagkotkanny structures in a zone of disteel phalanxes, in particular – the insignificant volume of fabrics causing formation of the powerful center of a local infection, and heavy violations of local blood circulation in a periosteum.
Feature of osteomyelitis of phalanxes of fingers is tendency to large-scale destruction of a periosteum. At osteomyelitis of other localizations the periosteum reacts to an inflammation formation of the so-called "bone box" providing a possibility of the subsequent restoration of bone structures even at their considerable destruction. At purulent process in phalanxes of it does not occur, the periosteum nekrotizirutsya quickly, its regeneration becomes only possible after excision of the sequester. At considerable fusion of the remained sites of a periosteum it appears insufficiently for restoration and formation of a full-fledged bone. The low probability of treatment and need of amputations at long or volume inflammatory process is explained by it.
Taking into account an etiology distinguish primary (arisen against the background of a trauma or hematogenic) and secondary (contact at other types of a disease) a bone felon. As osteomyelitis affects mainly disteel phalanxes, the classification allowing to define reasonably treatment tactics at this kind of pathology is developed. Allocate three types of defeat of bone structures:
- Regional or longitudinal sequester. Destruction of a bone has local character, the periosteum is melted slightly, perhaps complete recovery of a bone. In the presence of the regional sequester mobility of a finger after recovery remains. At longitudinal sequestration the distalny joint of a finger is involved in process, the anchylosis becomes an outcome.
- The sequester with preservation of the basis of a phalanx. Purulent process is localized above the bone basis, is not changed. Independent blood supply of epifizarny and diafizarny zones of a bone provides favorable conditions for its restoration at sufficient preservation of a periosteum. The decision on preservation or amputation of a finger is accepted individually taking into account the size of the sequester and duration of a disease.
- Full sequestration of a phalanx. The changed bone is surrounded with the cavity filled with pus from all directions. Suppuration extends to a joint and a tendinous vagina. The periosteum is destroyed completely or its small sites incapable of full regeneration remain. Amputation is required.
At secondary defeat disteel phalanxes I, II and III fingers usually suffer. In the beginning the characteristic clinical picture of a hypodermic felon which is followed by local hypostasis, hyperaemia, the pulsing pain on the palmar surface of a finger, weakness, weakness, temperature increase is observed. Then in the struck area the suppuration center which is independently opened on skin or is drained by the purulent surgeon is formed, local and general signs of an inflammation decrease. Distribution of pus on bone structures is shown by repeated strengthening of symptomatology which at initial stages of osteomyelitis, however, does not reach degree of the expressiveness characteristic of a hypodermic felon.
At primary defeat the felon develops sharply. The phalanx swells, skin reddens, and then becomes crimson and cyanotic, there are intensive pulling pains. The finger is in the provision of the compelled bending, the active and passive movements cause strengthening of a pain syndrome. The considerable general hyperthermia is noted, body temperature sometimes reaches 40˚C, oznoba are possible. When progressing primary and secondary process kolboobrazny expansion of a finger comes to light. Skin on the affected phalanx intense, smooth, brilliant. The phalanx is painful throughout. Sites of a necrosis are formed. The fistulas which are usually located in a subnail zone are formed. There can be deformations connected with destruction of myagkotkanny and bone structures.
At immunity violations, the wrong or untimely treatment the bone felon can pass in pandaktilit – an inflammation of all tissues of finger, including joints and sinews. In certain cases purulent process extends in the proximal direction. Brush phlegmon, deep phlegmon of a forearm, purulent arthritis of a luchezapyastny joint are possible. In hard cases the sepsis posing a threat for the patient's life develops. In the outcome the contractures, rigidity or ankiloza caused by rough scarring, damage of nearby sinews and joints, a long immobilization are quite often observed.
The diagnosis is exposed by experts in the field of purulent surgery at the appeal of the patient to policlinic, is more rare – at the emergency hospitalization in connection with the expressed phenomena of purulent process. In the course of diagnostics the characteristic anamnesis, a typical clinical picture of a disease and data of additional researches is considered. The plan of inspection includes the following events:
- Poll, survey. At primary process in the anamnesis the injury of a finger or existence of the remote purulent center comes to light. At secondary option is established that the patient within the last two or more weeks suffered from other form of a felon. At survey hypostasis, reddening and fistula with purulent separated is found. At accurate introduction of the probe the corroded surface of a bone is defined.
- X-ray analysis of fingers of a brush. A radiological symptom of a disease is the uneven enlightenment of a phalanx caused by jet osteoporosis in a combination to a stertost of contours, later – an izjedennost of contours and the center of destruction. Sometimes when progressing an inflammation the bone is almost not looked through that can be mistakenly regarded as a necrosis. At a necrosis the shadow of a bone remains, on its background the sequester which can be displaced eventually is checked. When involving a joint the articulate crack is narrowed, the jointed surfaces of bones become uneven.
- Laboratory analyses. The purulent inflammation is followed by characteristic laboratory changes: increase in SOE, leykotsitozy with shift to the left, existence in blood of a rheumatoid factor, S-jet protein and the Antistreptolizina-island. Crops of wound separated demonstrate existence of gnoyerodny microflora, allow to define its sensitivity to antibiotics.
treatment should be carried out only under the supervision of a doctor. Self-treatment is unacceptable!!!
Treatment only surgical. The place of a section is chosen taking into account an arrangement of fistula and data of the roentgenogram, based on the principles of the maximum preservation of functions and the working surface of a finger. Usually opening of a felon is carried out by expansion of the svishchevy course. Are subject to excision both bone sequesters, and the struck surrounding cellulose. Removal of impractical sites has the features connected with the insignificant volume of fabrics in this zone. At excision of cellulose do not use a scalpel or ordinary scissors, the changed segments take a mosquito, tighten on themselves and accurately cut off the site behind the site peaked scissors.
Then start removal of the affected bone which also has to be extremely economical. Freely lying bone sequesters excise. Separately located healthy sites which kept contact with periosty leave even at the uncertain forecast of their restoration. The wound is washed out a hard stream of hypertensive solution from the syringe. In the subsequent perform bandagings, supplement the general antibiotic treatment with introduction of antibiotics to the inflammation center.
In the absence of the prospects of restoration of a phalanx, threat of further spread of an infection make amputation or an exarticulation of a finger of a brush. At making decision on amputation of the I finger consider its functional value, whenever possible try to keep each millimeter of length even at threat of deformation and an anchylosis as the deformed or motionless finger is often more functional, than his stump. At considerable damage of other fingers the level of amputation is chosen so that to create a functional stump with a working surface, free from hems.
Forecast and prevention
The forecast of a bone felon is defined by prevalence of osteomiyelitichesky process, safety of a periosteum and degree of an involvement ok of ruzhayushchy structures. At timely treatment of regional sequesters an outcome usually favorable. In other cases in the remote period shortening and/or violation of mobility of a finger, cicatricial deformations is possible. Prevention consists in the prevention of production and home accidents, use of protective equipment (gloves) during the work with the irritating substances, the timely address to the surgeon at an inflammation and injuries of fingers, adequate opening and drainage of other forms of a felon.