Ingrown nail is a growth of the nail plate into the skin fold

Predisposing factors include tight shoes, flat-foot, excessive weight

Ingrown nail leads to constant trauma and associated infection
distribution onto the thumb (neurologic disorders, etc.)
(fungi). Medical therapy includes eradication of cause, proper nail
care, and local antiseptics (they are not always effective).

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 Medical treatment (above) and surgery of ingrown nail using
Surgery is indicated if the conservative therapy fails.
phenol application (below)
a) removal of the nail with necrotic tissues

b) removal of the nail with wage shape resection of skin folds at both c) removal of the nail with wage shape resection of skin fold and
sides resection of growth zone (growing point of the nailbed).

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 “Diabetic foot” syndrome
is a pathologic condition developing due to alteration of peripheral
Postoperative recurrence is least after “C” type of surgery
nerves, vessels, skin, and soft tissues. It is characterized by chronic
and acute ulcers, pathologic changes of the bones, joints, and
purulent-necrotic processes at patients suffered by diabetes mellitus.

According to data provided by WHO the diabetes mellitus is a common condition Within one year after amputation the incidence of mortality is 11-41%,
affecting approximately 175 mln. persons at our planet. The rate of incidence is within three years – 20-50%, within five years – 39-69%.
expected to rise till 240 mln. at year 2010. Social importance of disease is obvious.
Frequent outcome of diabetes mellitus is an early handicap, high rate of myocardial
infarction, morbidity, and amputation of extremity. Rate of amputations is
extremely high, approximately 17 to 45 times higher than at patients not affected by
diabetes.

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 PATHOLOGY
Diabetic sensory neuropathy is characterized by weakness, burning
sensation, muscle cramps, paraesthesias, etc. Loss of sensation
predisposes a patient to overlooked skin trauma and development of
ulcers and even advanced infection.
One of the most devastating consequences of neuropaty, or, more
exactly, osteoarthropathy is a development Charcot cubic foot. It is
characterized by destruction of plantar metatarsal joints followed by
excessive loading of several areas of the foot by body weight
Motor neuropathy leads to changes in the foot muscles resulting in
change of gait and appearance of areas of excessive pressure at the
foot during walking causing formation of calluses and ulcers at the
foot.
Another common type of foot deformation is caused by toe muscle
atrophy resulting in ulcer formation near tarsophalangeal joints. X-
ray shows diabetic osteoarthropathy. The ankle joint (10%), tarso-
metatarsal (60%), and tarsophalangeal (30%) joints are often affected.
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Autonomic neuropathy is caused by sympathetic denervation of
The picture summarizes all the pathophysiologic events at
vessels and dilation of arterio-venous shunts, depriving the cells of
patients with diabetic neuropathy
oxygen. The second event is a loss of sweating followed by dryness,
calluses and cracks of the skin and development of ulcers and even
advanced infection.

Involvement of arterial tree is called diabetic peripheral angiopathy. Thus, a diabetic neuropathy and angiopathy are the leading
It leads to second form of diabetic foot – ischemic (or pathologic processes at patients suffered by “diabetic foot”
neuroischemic). Changes of peripheral vessels are the leading cause syndrome. They may coexist and further aggravate prognosis for a
of early amputations. Coronary, cerebral, and renal arteries are also patient. These changes are the background to development of
commonly affected. The feature of diabetic angiopathy is that the purulent and necrotic complications.
q y involved (distal
small arteries are frequently ( block)) whereas the large
g
ones are intact

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 Suppurative infections at diabetic patients are common (due to
aforementioned factors). Readily portals of entry, poor blood flow,
decreased immunity, etc. all predispose to fulminant course of
infection characterized by extremely rapid and excessive spread of
process.
Classification of diabetic foot
1) neuropathic infected form (60 to 79% of cases) is associated with development of
purulent and necrotic processes on the ground of diabetic neuropathy
2) neuro-ischemic form (30 to 40% of cases, at patients of advanced age) is
associated with development of purulent and necrotic processes on the ground of
alteration of both nerves (diabetic neuropathy), and major arteries (diabetic
arteriopathy). Coexistence of two pathologic factors and surgical infection is
associated with poor prognosis the extremity to survive.
Ulcer (or any other skin injury) represents readily portal of entry to
infection. The possible polimicrobial spectrum of bacteria is shown
making antibacterial therapy most challenging.
Clinical picture and examination of a patient
Patient’s complaints may vary depending on the type of foot changes.
Neuropathic form (local data) uncomplicated uninfected ulcer is
characterized by typical location and absence of signs of local
infection, palpation of the ulcer is commonly painless, the depth may
be different, sometime reaching the bone. The foot is warm
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 Most severe cases of phlegmon may be accompanied by extension of
Infection of the ulcer leads to penetration of bacteria to the depth of phlegmon at the calf. At extreme cases the wet gangrene or sepsis
the foot with possible development of cellulitis, arthritis, phlegmon may develop. Such complications are the result of inadequate
(most common) with typical signs etc. surgical and medical treatment

Neuroischemic form of diabetic foot is characterized by the pain Clinical differentiation of both forms of diabetic foot
(intermittent claudication). But sometime it is absent due to
neuropathy. So it is possible that the first clinical sign would be
development of necrotic complications which are extremely difficult
to control (high risk of amputation)

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 Hand-held Doppler ultrasound: the beam is sent on an artery
Laboratory and instrumental investigation (blindly, according to anatomic location and projection of the
vessel onto the skin) and the reflected beam is picked up by a
multidisciplinary approach to a patient is necessary with involvement receiver. Reflection of the beam by moving cells changes the
of a general surgeon, angiosurgeon, endocrinologist, therapist, and frequency in the reflected beam. That frequency change may be
converted into an audiosignal (or traced on the monitor) with
podiatr. characteristic for artery pulsating sound. Therefore it may be used
 A) Common laboratory and instrumental investigation: as a very sensitive
iti ttype off stethoscope
t th in
i conjunction
j ti withith
sphygmomanometer to assess the systolic pressure in relatively
CBC, urine analysis, blood chemistry, glucose level, glycemic small arteries.
profile, coagulogramm, immunogramm, ECG, Echo–CG, Chest
X-ray
 B) Assessment of extend of necrotic process:
foot X-ray (two planes), CT of the foot and calf, culture and AB
sensitivity
ii i
 C) Assessment of arterial involvement: Doppler US, duplex
scanning, arteriography, transcutaneous partial oxygen pressure
 D) Assessment of peripheral neuropathy: investigation of pain,
vibration, and temperature sensitivity, tendon reflexes

Ankle/brachial index (ABI) is the ratio of the systolic pressure at the Duplex scanning A Duplex scanner uses B-mode ultrasound to
ankle to that in the arm; N = 1,0; values below 0,9 indicate some provide an image of vessels (because of ability of different tissues
degree of arterial obstruction. A value of less than 0,3 suggests to reflect the ultrasound beam). A second type of ultrasound beam
imminent necrosis. (Doppler ultrasound) is than used to insonate the imaged vessel

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Some duplex scanners have the added sophistication of color coding Transcutaneous partial oxygen pressure (TcPO2) measurement.
(triplex).

Arteriography cannulation of an artery followed by injection of a

radiopaque solution into the arterial tree using Seldinger technique is Treatment
common. Most precise information is provided with this Control of blood glucose level (injection form of insulin)
examination, but the method is invasive, possesses risk of hematoma,
thrombosis, arterial dissection, and anaphylactic complications.

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 Approach to medical treatment
Approach to local medical treatment
Symptomatic: NSAID, Vitamins of B group, cease smoking
 Daily surgical necrectomias are accompanied by local care
Antibacterial: empirical
p ((to cover G+,, G-,, and anaerobes)) is followed taking into account the stage of wound healing process:
by accurate administration according to results of antibacterial  1st stage: antiseptics, collagenases
sensitivity test. Parenteral route is preferred, duration is 2 to 3 weeks
 2nd stage: different protective agents (ointments)
(at patients with deep necroses even if well drained)

Antiaggregative (antiplatelet drugs): sulodexide i.v., i.m.,

(glicosaminoglican containing agent reduces platelet aggregation);
orally – ticlopidin, dipyridamole, aspirin.

Prostaglandin based agents are used at critical ischemia – alprostadil,

vasoprostane – vasodilating, angioprotective, rrheolytic,
antiaggregative, and fibrinilytic action

Approach to surgical treatment Extend of surgical treatment is influenced by the type of the foot
wound . Wagner’s classification is given
The principles of surgery are the wide incision, adequate draining
and excision of necrotic tissues, prevention of further spread of
infection.

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 Ulcers belonging to 1-2nd Wagner class are treated with bone Extensive phlegmon of dorsal aspect of the foot requires its wide
resection and plastic closure of the wound exploration (Wagner class 3 )

Extensive phlegmon of the plantar surface of the foot requires its Extensive phlegmon of the plantar surface of the foot
wide exploration (Wagner class 3) requires its wide exploration (Wagner class 3)

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Extensive phlegmon of the of the foot may extend onto the Phlegmon of the heel area of the foot requires its wide
calf, thus requiring its wide exploration (Wagner class 3) exploration (Wagner class 3)

The possible types of limb-saving amputations are shown: The possible types of limb-saving amputations are shown:

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 The possible types of limb-saving amputations are shown: The possible types of limb-saving amputations are shown:

Best treatment is the prophylaxis

After extensive surgical resections the skin defect is to be
closed. The following methods of wound closure are used:

- secondary suturing
- split thickness skin graft
- local skin flaps
- combined plasty

 At patients with ischemic form of diabetic foot a surgical

reconstruction of arterial vessels is planned to improve
blood flow into the ischemic limb
limb. Questions of arterial
reconstructive surgery will be discussed at the next
semester.

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 Anatomic areas of the palm

Common medical terms used to describe palm actions Panaritium is a common term describing any suppurative infection of
digits. 15 to 20% of surgical cases are caused by that pathology

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 Etiology Classification
Little trauma (incisions, stab wounds, abrasions, bites etc.) a) Superficial: cutaneous, subcutaneous, paronychial, hyponichial.
b) Deep: osteal, tendinous, articular, pandactilitis.

Possible extension of different types of panaritium Paronichion

Pathology and clinical picture
Infection is commonly located below the nail fold (paronychion) or
under the nail (hyponychion) causing local signs of infection

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 Subcutaneous panaritium (pulp abscess, felon)
Pathology and clinical picture Flexor tenosynovitis (tendinous panaritium)
Infection is commonly localized under the skin with apparent local Characteristic clinical picture
signs. Movements are not painful.

Tendon sheath infection (infection tenosynovitis, tendon panaritium) Suppurative arthritis (articular panaritium)
characteristic local clinical picture is accompanied by general signs, clinical picture includes local signs of infection, (with advanced
lymphangitis, lymphadenitis, etc. infection a pathologic mobility and crepitation develop due to
destruction of ligaments), painful movements, etc.

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X-ray picture of the articular panaritium Osteomyelitis of the finger bone (osteal panaritium)
usually results from further progress of infection caused by
subcutaneous panaritium. Radiological picture of bone destruction
is evident only at 10-14 days after beginning of clinical picture

Pandactilitis
It is a possible outcome of advanced or poor treated panaritium.
General signs of infection are prominent.

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 Surgical treatment
Surgery of uncomplicated panaritium is done under digital nerve
block anesthesia. I.V. general or brachial block are used at severe
cases.
Different types of surgical aid depending on sort of pathology
Surgery of panaritium may also be done using the following
types of nerve block anesthesia.
Paronychion and hyponychion surgery: Direction of incision. The nail root should
be exposed. Incision proximal to the corner of the involved nail. If the abscess
extends around the nail base or lateral margin, the base or margin should be
excised for adequate drainage and removal of nonviable nail. The fingernail will
regenerate from the nail bed.
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 Panaritium surgery
types of insisions depending on localization of infection (an incision
never crosses the skin creases and area of median nerve distribution)
Incision and drainage of felon with preservation of sensory digit pulp.
Because of the scar, this incision should be used only if the infection
is already pointing to the volar surface. A centrally located incision
permits excellent drainage but does leave a scar in the finger pad
Common volar and dorsal incisions for the hand
Panaritium surgery
Types of wound draining (left) Subcutaneous panaritium of the
terminal phalanx: two contrapertures are done using two curve
midaxial incisions for adequate draining using plastic tube drain
(right).
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 Articular panaritium Surgical treatment of flexor tenosynovitis
Surgical wide arthrotomy and draining are used if joint surface is not The incision is placed at the neutral midaxial line (left). End-on
damaged. Damaged surfaces need to be resected view of incision, the web extension of incision is not always
necessary for exposure (right)

Surgical treatment of flexor tenosynovitis

Surgical treatment of flexor tenosynovitis
Exploration of a tendon sheath is followed by implantation of
Closed irrigation of flexor sheath infection using two incisions
irrigating catheters and multiple postoperative instillations effectively
and a small catheter
control many infections

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Pandactilitis commonly requires emergency amputation to prevent
extension of infection at the palm and forearm. If the bone is not
totally destructed and draining is well, the digit may be saved.
Horse-shoe phlegmon
Anatomy of synovial sheaths and pathologic mechanisms of
infection extension
Complication of panaritium or independent palm infections:
U (horse-shoe) phlegmon, thenar and hypotenar infections,
midpalmar phlegmon, Web (or corn) abscess . Risk of extend of
infection may require additional incisions to explore deep forearm
compartments.
Deep spaces of the palm and forms of infection
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 Clinical picture
Palmar infection is always accompanied by general signs of infection,
Forms of palm infection lymphangitis, and edema that is most evident on the dorsum of the
hand irrespective of the site of the lesion

The main lymphatic trunks

of the forearm and arm

Surgical treatment Surgical treatment

Incision for draining a web space abscess Localization of surgical incisions to drain deep forearm
phlegmon due to spread of process from the palm

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 Medical treatment Elevation of swollen hand
Postoperative immobilization at the position of function,
antibiotics, and elevation of the hand are to be done

Fingers flexed to nearly 900 at metacarpophalangeal joints and minimally

flexed at the interphalangeal joints with thumb abducted and wrist dorsiflexed

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