Vі. System of teaching tasks for verification of the final level of knowledge

Situation tasks

1. Patient has 26 years ago and grumbles on a pain in a right hand which is marked 4 days. The pain at the beginning appeared at foundation ІІ and ІІІ fingers. Then an edema and intumescence of the dorsal surface of the hand became quickly to increase. ІІ and ІІІ fingers are half-bent in interphalangeal joints, unbended and divorced in metacarpal-finger joints, the hand has the appearance of “rakes”. What will be your diagnosis and tactic of the treatment of this patient?

Answer: The patient has the phlegmon of the second interphalangeal space of the right hand. He must be operated – it is the opening of the apostasis in the area of most sickliness on palm's surface by a longitudinal incision in an interdigital space with a counterpuncture on the dorsal surface of the hand. An immobilization of the hand is needed after the operation.

2. On a reception to the surgeon a 53-years-old woman with complaints about an itch and burning of skin came on ІІІ finger of left hand. It is known from anamnesis, that 3 days ago the patient at home cut fish and pricked the finger by bone of the fish. The edema and| hyperemia of the finger appeared in a day. The spot of hyperemia with a cyanotic tint is marked at examination on the back-lateral surface of the finger. The edges of the hyperemia are scalloped. The finger is hydropic; motions in interphalangeal joints are limited and painful. What disease is it needed to think about? What pathology is it necessary to conduct differential diagnostics with? What method of treatment will be applied for this patient?

Answer probably the erysipelas of the III finger of the left hand skin form takes a place at this patient. This disease must be differentiated with a skin, hypodermic and articular panaritium, an exudate erythema, arthritis. The conservative treatment is indicated for the patient.

3. A patient grumbles about the throe pulsating pain in ІІ finger of the right hand. Four days ago she pricked the finger at cutting of fish. Last two nights she could not sleep from th pain. The nail-bone of the finger has swollen, the swelling and sharp sickliness is marked on its palm's surface. Motions in interphalangeal joints are gently limited. Inguinal lymph-nodes are not increased. What is your diagnosis? What help must be rendered this patient.

Answer: the patient has the hypodermic whitlow of the ІІ finger of the right hand in the phase of purulent inflammation. The abscess must be opened. A surgical attack can be executed under a local anesthesia.

4. The patient K. has 36 years ago, pricked by a rope deeply the І finger of the right hand. After days an edema and pulsating pain appeared in the finger. He did not apply for medical help and only two sleepless nights compelled him to come on reception to the surgeon. The nail-bone of the finger is incrassate like a mace; sickliness is marked at palpation by the probe of practically all of palm's surface of distal phalange. Limitation of motions takes a place in the interphalangeal joint. What will your diagnosis and possible operative incision cut be?

Answer: the hypodermic panaritium of the nail phalanx І finger of the right hand is at the patient. It is necessary to execute two lateral incisions for opening of the abscess. Immobilization after the operation is needed.

5. The sick came on a reception with a purulent hypodermic panaritium of ІІ finger of the right hand. Indications to the operation are absolute. The consent of the patient to surgical attack is got. But the effective draining of blood of the finger is needed before dissection carefully to delete all nonviable tissues. How will you create it?

Answer: the dry operating field at operation on the finger can be created by imposition of a tourniquet on the basis of finger. The tourniquet is laid on the preliminary anaesthetized area to decrease the pain feelings from a clench.

6. A mother brought to a reception to the surgeon a boy 9 years ago which is disturbed by pain in the І finger of right hand. He is ill for 3 days. The area of the swelling of turbidly-white color with diameter to 0,8 cm which is surrounded the thin strip of hyperemia is determined at the examination on palm's surface of the nail phalanx of finger. What help must be rendered a child?

Answer: The boy has a skin panaritium of the І finger of right hand. The abscess is opened up, the exfoliate epidermis is removed, a revision is done in the presence of a fistula in a hypoderm, a bandage with antiseptic is laid.

7. The patient O., 44 years ago, appealed with complaints about pain in the І finger of left hand. She is ill about week from the moment of deleting of a splinter (fish bone) from under a nail. At once pain was insignificant. She applied baths with a salt solution, with potassium permanganate, put compresses with Vishnevsky's ointment, baked onion. An improvement did not come. The sleepless night the day on the eve compelled to come to the doctor. The dimness as a triangle in the center of nail plate is determined at examination. Pressure on the nail plate causes sharp pain. Motions in the interphalangeal joint are full. What will your diagnosis and medical tactic?

Answer: The subungual panaritium of the I finger of left hand is presented at this sick. The some operation is indicated – it is a wedge-shaped resection of nail plate above the area of purulent process.

8. A man, 35 years ago, with complaints about moderate pain in the area of nail phalanx of the ІІ finger of right hand appealed to the policlinic. Pain disturbs for two weeks. The secretion of a purulent content appeared from an appearing fistula on the nail phalanx of the finger in 5 days from the beginning of disease, after it pain diminished. Pain and edema of the finger were periodically increased then, but a facilitation came after the output of pus. For the last days intensity of pain increased again, and the edema of finger began to grow in the area of nail phalanx, the pus did not depart. It is discovered at an objective inspection: it was swollen hyperemia (the color of skin was cyanotic with a purple tint) of the nail phalanx of the ІІ finger of right hand spreading on distal part of the middle phalanx. There is fistula by a diameter to 2 mm from which at pressure the trace of purulent exudate is selected on palm's surface of the phalanx. Research by the bellied bougie discovered the area of the expressed sickliness for all of nail phalanx of the ІІ finger of the right hand. The focuses of destruction of the distal phalanx are exposed on the sciagram of this finger. What will diagnosis be to this patient? What will the tactic of treatment?

Answer: The bone panaritium of the ІІ finger of the right hand is at the patient. The operation is indicated (sequesterectomy) with the using in the postoperative period of the "closed" method of treatment.

9. The patient, 35 years ago, has entered to the clinic with the diagnosis tendinous panaritium of the І finger of the right hand. What order must it be executed him operation, and what method of anaesthetizing here must be applied?

Answer: The patient must be operated in an urgent order under a general anesthesia (intravenous narcosis).

10. The patient, 9 years ago, has entered to the clinic. The diagnosis is set for her. It is the hypodermic panaritium of the ІІІ finger of the left hand. The purulent-necrotizing process is localized on the nail phalanx. Last time the child ate and drank 1 hour ago. What must tactic of a surgeon be in this case?

Answer: The child needs to execute an urgent operation concerning the panaritium under the general anaesthetizing. The operation will be executed in 3 hours after the reception of meal (such term is needed for the prophylaxis of complications during implementation of the anesthesia).

11. The patient, 73 years ago, has entered to the surgical department in 15 days from the beginning of the disease. She complains about moderate permanent pain in the V finger of the right hand, on pain and slight swelling of the hand in the area of the antithenar, on a hyperemia to 39^oС, on general weakness and thirst. It is known from anamnesis she for 25 years has diabetes mellitus ІІ type, for some time past for the correction of the level of sugar| she used Maninil. It is discovered at examination of the right hand: the V finger is incrassate with the areas of necrotic skin; there are purulent fistulas by the diameter 2 and 3 mm on the nail and the middle phalanxes, purulent content is exuded from these fistulas. At palpation of the finger a crepitation and pathological mobility is determined in the proximal interphalangeal joint. The area of the antithenar is infiltrated, a hyperemia of the skin here is unexpressed, the symptom of fluctuation is not determined. The sickliness is exposed on space of tendon vagina at the research by the bellied bougie. What will you determinate preliminary diagnosis? What additional methods of research must be applied for this patient? Will tactic of treatment consist in what?

Answer: The preliminary diagnosis is pandactylitis of the V finger of the right hand. The phlegmon of the antithenar can be presented and the tenosynovitis of the flexor of the V finger.

Additional methods of research: sciagraphy of the right hand, diagnostic puncture of the area of the antithenar, general analysis of blood, blood test on sugar, general analysis of urine and test on acetone of urine.

Taking into account that this patient has diabetes mellitus ІІ type and has age 73 years, it is necessary to execute the operation an exarticulation of the V finger of the right hand. Opening of the phlegmon of the antithenar is needed at an exposure of the pus in time the puncture or in the vagina of the tendon during an operation.

It is necessary to include medicines for correction of the level of sugar (insulin therapy) to the generally accepted complex of medical measures and also making better rheological properties of blood and microcirculation (Reopolyglucin, Trental, Xantinol nicotinatis and other).

12. The sick, 34 years ago is hospitalized in the surgical department with complaints about pain in the index finger of the right hand on 22 days from the beginning of the disease. It is known that he was operated concerning a hypodermic panaritium in a policlinic on 8th days from the moment of the disease. After the operation he applied baths with salt solution, bandages with Vishnevsky's ointment. UHF-therapy was used. In two weeks such treatment an improvement did not come. The nail phalanx of the finger is incrassate, sickly. On a radial surface it's the linear wound is with surplus granulations and scanty seropurulent exudate. What complication did develop at this patient? What additional researches are needed to be executed with the purpose of verification of the diagnosis?

Answer: Probably the hypodermic panaritium of this patient was complicated a boned panaritium. That is more frequent than all conditioned a small cut, insufficient revision of the wound, poor draining. It is necessary to execute the sciagraphy research of the finger.

13. The patient G., 23 years ago, has entered in the surgical department with complaints about pain in the ІІ finger of the left hand. Two a week ago he pricked his finger a metallic scobs. During the last week he was treated in a policlinic: a puncture, antibiotics and an immobilization. An improvement did not come. He was directed on the stationary treatment. The finger in the proximal interphalangeal joint is half-bent, fusiform incrassate, hydropic, the skin is with hyperemia, palpation in the area of joint sharply sickly, motions in the joint are practically absent. What is your diagnosis? What additional researches must be executed? What will your medical tactic?

Answer: The patient has the arthral panaritium of the proximal interphalangeal joint of the ІІ finger of the left hand. It is necessary to execute some sciagraphy research of the finger. An operation is indicated to this patient.