Why a treatment surgical treatment of this panaris is– necessary ?
A panaris is a infection bacterial from fabrics soft from finger. He corresponds to a abscess and evolves at several phases :
- The first phase is that of inoculation, stinging, small wounds, manipulation of periungual skin, nail biting, etc…. The initial accident may be trivial or minimal, or even go unnoticed.
- The next phase is inflammation with swelling and localized redness. At this stage, you may have been offered non-operative treatment with dressings or antiseptic baths, which may suffice to cure the infection by immune reaction.
- If this treatment isn’t enough, panariasis quickly becomes painful, with pulsating, throbbing, often sleepless pain, as the fingertips are very sensitive. The finger is swollen, and pus can sometimes be seen through the skin or leaking out. In this case, the panicitis is said to be “mature” and needs to be operated on. There is no longer any room for non-operative treatment, such as antibiotics.
Why intervention is necessary:
This is an infection of the hand, which is always serious.
Because of the nature of its tissues, the hand has little defense against infection. The risk is that the infection will spread. All infected and necrotic tissue must be removed to halt the spread of infection.
What might be the evolution in the absence of intervention?
Infection can spread locally to the noble structures of the finger (bone, joint or tendons, which defend themselves poorly against infection), or through the lymphatic (lymphangitis) or blood (septicemia) system.
To be precise, there are several types of panarias depending on where they are located on the finger:
- The most common is periungual panicitis, which affects one of the skin folds around the nail, often after manipulation of the periungual folds, “the skins” or nail biting. The risk of this type of infection spreading is linked to the immediate proximity of the nail and its matrix, which can become infected. The distal interphalangeal joint, which lies beneath the nail matrix, can become infected with infectious arthritis. The extensor tendon may be affected
- Pulpal” panic attacks the palmar pulp of the finger. The risk is purulent necrosis of the finger pulp, which may be total, and damage to the finger’s sensory nerves, flexor tendon or bone, which may have to be excised. The pulp is the organ of prehension and touch sensitivity. These structures cannot be reconstituted.
- Anthracoid panaris is a kind of boil on the dorsal skin of the proximal phalanges. An associated form is the “shirt-button” panicitis, which is a dorsal or peri-ungual panicitis that spreads in depth, becoming pulpal. It represents an already late and more serious form.
2- Visit dérorthement de l’ intervention .
A intervention you will be proposed at emergency or in a deadline quickly.
Before surgery surgery :
The organization of surgery, even in an emergency, entails a delay depending on the possibilities of the various parties involved and the availability of the operating theatre, particularly with regard to the management of other emergencies. During this time, additional examinations may be prescribed.
X-rays to check for foreign bodies or skeletal lesions.
An infectious blood test may be indicated in the event of signs of diffusion.
Antibiotics can be administered if there are signs of widespread infection.
The anaesthetist will see you before the procedure, and will need to know your history, as certain pathologies can interfere with the infection (diabetes, immunodepression, arteritis, renal insufficiency, etc.) and your current treatment.
Several types of anaesthesia can be offered: loco-regional (upper limb anaesthesia only) or general anaesthesia, particularly if there are signs of spread of infection, sometimes contraindicating the previous technique.
Tobacco reduces tissue oxygenation and vascularization. It promotes the spread of infection, and must be stopped as soon as the infection is diagnosed. Nicotine substitutes or a specialized consultation will be offered to you postoperatively if you have difficulty weaning yourself off the habit.
Surgery:
It is performed under a pneumatic tourniquet (cuff on the arm or forearm) or sometimes under a finger tourniquet to avoid bleeding during the procedure and to allow the surgeon to better visualize infected areas.
It involves excision of all infected tissue and surgical exploration of the infected tissue. In the case of a skin infection, the infected skin must be removed (excision of the plague).
The gesture is usually quick, which may surprise you but shouldn’t minimize its importance.
Complications during surgery :
They are rare, and usually result from the discovery of the extent of the infection.
The surgeon will be guided by the appearance of the tissue to determine the extent of tissue excision. It is important to remove all infected tissue to avoid rapid spread or relapse of infection.
Bacteriological samples are taken to guide antibiotic therapy. Antibiotic treatment is not systematic, but may be required in the case of a severe form, unfavorable evolution or a particular history.
The nail may become infected and have to be removed, but will grow back without sequelae if the matrix is not affected. Damage to the nail growth zones: matrix and nail bed, can leave nail sequelae: deformation, striae, growth defects, etc.
If a tendon infection is discovered, the surgeon may decide to remove the infected tendon during the operation, in your best interest. If the infection is too far advanced, it cannot heal despite antibiotics.
Joint infection must be treated in its own right, which may require immobilization with splints, pins or mini external fixators.
The skin infection may be more extensive than is visible (particularly in the case of melanodermal skin), necessitating a more extensive excision than would be expected.
Lastly, since any surgical operation is a complex process, it can be postponed – even on the operating table – if the conditions are not ripe for success, in line with current recommendations.
The surgeon will inform you postoperatively of the findings, prognosis and treatment plan.
Postoperative:
Foreseeable evolution :
In most cases, outpatient hospitalization is sufficient.
The dressing will be redone in consultation and checked to ensure that the wound is progressing correctly.
The wound will then close on its own through directed healing, which may require daily dressings at first.
Depending on the size of the initial excision, healing is generally achieved in 2 to 4 weeks.
Wounds and dressings are the source of discomfort, and often of initial work incapacity, especially for manual or hygiene-regulated professions (cooks, nurses, etc.).
Painkillers will be prescribed as soon as pain is detected in the emergency room, particularly for operations or dressings. It is important to inform the care team of any such pain, so that treatment can be adapted accordingly.
Nail re-growth is usually disrupted for several months, with the final appearance only achieved after around a year.
Sometimes the situation is more serious:
Despite surgery and treatment, the infection progressed, necessitating further surgery.
If extensive tissue removal is required, reconstructive surgery will be the goal. This is only indicated once infectious phenomena have ceased.
This may involve plastic surgery to close wounds using skin grafts, vascularized tissue grafts (skin flaps), or multi-stage tendon reconstruction procedures.
Any serious hand condition may therefore require hospitalization and prolonged care. The surgeon will explain the various options available to you in the first few days, depending on the progress made.
Despite surgery and anti-infective treatment, complications are possible:
Occasionally, the spread of infection, despite all treatment, leads to iterative surgery and tissue excision. This can lead to a deterioration in the vascular state of the limb segment, which may no longer be irrigated, or an inability to maintain limb segment function, particularly if nerves have been affected.
In exceptional cases, the evolution of the infection may require your surgeon to discuss amputation of a finger segment. General spread of the infection, with sepsis, may be life-threatening.
Care itself can be a source of complications: complications of infusions, complications of immobilization, complications of antibiotic treatment, decompensation of pathologies that were quiescent or well-controlled.
Longer-term sequelae are possible:
The treatment phase can entail prolonged care, and therefore a potentially lengthy period of incapacity.
Aesthetic after-effects on the nail are common, and joint stiffness is easy to develop, and can be treated by rehabilitation, which can be prolonged.
Pain in the acute phase may be severe, and may persist to some degree over the longer term. Additional treatment may be required, particularly in cases of complex regional pain (algodystrophy). Cold intolerance with pain and changes in finger color may be sequelae.
The scars imposed by surgery and tissue excisions can be significant, unsightly, permanent and sometimes painful. Skin reconstruction surgery may be discussed.
Your cooling-off period :
As this is an urgent situation, the usual cooling-off period before agreeing to the operation should be as short as possible, in your best interests.
However, your surgeon can answer any questions you may have.
This information sheet is not exhaustive. Some complications are particularly exceptional and may arise in a specific context. It is important to understand that not all complications can be described exhaustively.
