Surgery 4 th Stage Lecture(2)

1. D.H.Zaini kufa- university Acute Supportive Teno-synovitis Surgery 4th Stage Lecture(2)

2. Acute Supportive Teno- synovitis Surgery...D.H.Zaini Kufa - university 4th stage -Lecture (2) Inf. of sheath of flexor tendon due to bact. (staph. Avreoll or st. poogen ) . This produced by point of needle or sharp object penetrating the hand. . This is the must feared infection of hand. . Pus within sheath destroy the gliding mechanism Adhesion this create adhesion lead to loss of tendon function & reduce movement.

3. The classical signs (local):- 1- symmetrical swelling of entire fingers. 2- flexion of fingers with sever pain on extension (Hook sign). 3- tenderness over the sheath. • The condition must be treated aggressively, there is no time for conservative treatment. transverse incision at the opposite end of tendon sheath with thorough irrigation with normal saline in late cases need excision of necrotic tissue.

4. Complication if late Dx &Rx --- 1- the forearm through the hand through ulnor & radial bursa, so must do drainage. 2- if infection continue for 14 days, x-ray of the hand to look for evidence of bone necrosis with possibility of no opaque foreign body that localized only by u\s. • Opaque revealed by x-ray. bursa is a synovial sheath cover the tendon. if x-ray several signs or features of osteomylitis (rosefication) & this need not only irrigation & drainage , But also need curatio which is mean remove this necrosis to prevent frequent pus discharge .

5. 3- supportive arthritis & if not treated well stiff joint stiff digit (functionless). 4- paralysis of median N. by compression .by distended radial or ulnar bursa. • Viral infection.. Herpes simplex infection look like Acute paronychia but with multiple vesicles that filled with infected fluid ( serous) rich with viral Ag. • Fungal infection.. Specially in housewives - tea workers} ch. Paronychiaeg. Yeast infection.

6. Barber pilonidal sinus.. • Pilonidus sinus hair follicle cavity blind tract. • It occur mainly in hairy aria, the commonest site is natal cleft in lower part of socrum (above coccyx) , But in the Barbers occur between 3rd & 4th finger in web space ...in work the hair enfer this area & with organisms produce chronic infection & discharge. • It is not easily treated & not resolved by antibiotic & drainage because it is sinus & each sinus or fistula in the body should be exiced ( the fibrous tract should be exiced because it is not usual tissue in this area)

7. Human & Animal loite.. • human bite is more dangerous than animal. • The commensal organisms in human mouth is more dangerous than that of animal mouth. • These organisms of human mouth called Vincent organisms . That is not found in animal. • Animal bac. Is more liable & susceptible to Antibiotic while human bite is more resistance to antibiotic &need aggressive Rx *excision of area is must. *extensive irrigation. *primary closure is C.I. *give anti- tetanus toxioids *prophylactic broad spectrum antibiotics. • If animal bite & open wound washed &closed &give antibiotic &vaccine if rabies is suspected.

8. Foot Infection Drainage open wound & drain Aspiration by syringe • Mainly occur in bore footed • It is similar to that of the hand • The main thing is should (1) look for lymph drainage which is mainly in the grain , but also should look for political fessa. (2) the urine must be examined for the sugar. (3) examine fully for arterial by examine pulse or Doppler.

9. Treatment 1- aggressive washing of foot by water &salt because hypertonic detergent may cause abrasions or burn that more liable for infection because of distortion of skin protective barer . No detol or provident iodine. 2- bed rest. 3- elevation of the foot specially for sever infection. 4- infected blisters (from ill fitting shoes ) should be a spirited by syringe. if clear fluid no problem. if purulent & thick infected pus &should use AB mainly anti-staph ( floxacillin).

10. Ingrowing toenail • Mostly seen in sweaty feet in light shock. • +ve family history in first & second degree as many pt. have wide freshy nail folds & thin nail plate. Rx (1) conservative . daily wash with water & salt . elevation . change the shock (very imp.) . if there is evidence of infection pus with sever pain give antibiotic mainly anti-staph &some times add metronidazole for anaerobic infection specially indiabetes

11. (2) Wedge resection of nail (1\3 or 1\4 of the nail with nail base to prevent recurrence) & at the sometime use phenol ( to destroy the remaining cells that may produce recurrence)-applied phenol for at least 3 min. Note nail base is the growing site & if not exiced this lead to recurrence. • After applied phenol, should leave the wound open with daily washing & dressing for at least 14 d. &give antibiotic. • If chronic infection & recurrence excision of whole nail & nail base Zodik procedure.

12. Note Ingrowing toe nail:- A painful condition of a toe (usually big toe) in which , or both edges of the nail press into adjacent skin(usually in medial side of the toe). This produce inflammation, redress, tenderness &throbbing pain, &may complicate by infection later.

13. Paronychia of toe same as hand nail. • Infected Adventitial Bursa.. • Mostly occur in those with deformed foot e.g. halluxvalgus • Corn become infected at bursa of big toe. • infection of heel space.. • Might be either intradermal or infection of the fat pad. • Thick &very tender area (because no space for pus accumulation ) & pt. unable to stand with throbbing pain. • Should be drainage &not wait fluctuation mean cavity with fluid ( pus accumulation) & should excised on the:- medical or late. Sides of the heel , not in the heel because this lead to scar & so pt. will not be able to stand .

14. Deep planter Abscess .. • Central plantar space is situated deep to plantar fascia (very thick) within the flexor tendons of toes. • Very deep & danger infection &nee draiage. • Note . In any infection every where must look for vascular diseases , diabetes & if the time is allowed for us to take a swab send for culture & sensitivity before starting an antibiotic. But critical cases such as diabetic foot septicemia. • Should take swab and start Rx as usual antibiotic to suspected organism. • In diabetic foot it is mainly P sendomenas infection that need eiprofloxun.