Pyogenic Flexor Tenosynovitis

Introduction

Infection of the synovial sheath that surrounds the flexor tendon
Mechanism
- causes include
  - penetrating trauma to the tendon sheath
  - direct spread from
    - felon
    - septic joint
    - deep space infection
Organism
- most common pathogen is Staph aureus
- gram negative and anaerobic infections commonly associated with
  - IV drug abusers
    - significant risk of MRSA infections
  - diabetes
  - farmyard injuries
  - animal bites
Associated conditions
- May develop into "horseshoe abscess"
  - many individuals have a connection between the sheaths of the thumb and little fingers at the level of the wrist
  - infection in one finger can lead to direct infection of the sheath on the opposite side of the hand resulting in a condition known as a "horseshoe abscess"

Anatomy

Flexor tendons
- tendon sheaths
  - functions to protect and nourish the tendons
  - extend from
    - the DIP joint to the midpalm in the index, middle, and ring fingers
    - from the DIP joint to the wrist in the little finger
    - from the IP joint to the wrist in the thumb

Presentation

Symptoms
- pain which developed over the last 24-48 hours
  - usually localized to palmar aspect of one digit
Physical Exam
- Kanavel signs (4 total)
  - flexed posturing of the involved digit
  - tenderness to palpation over the tendon sheath
  - marked pain with passive extension of the digit
  - fusiform swelling of the digit
- increased warmth and erythema of the involved digit

Imaging

Radiographs
- recommended views
  - radiographs usually not required
MRI
- cannot distinguish infectious flexor tenosynovitis from inflammatory but may help determine the extent of the ongoing process

Treatment

Nonoperative
- hospital admission, splinting of the hand, IV antibiotics, close observation
  - indications
    - early intervention
  - outcomes
    - if signs of improvement within 24 hours, no surgery is required
Operative
- hospital admission, I&D of flexor tendon sheath, IV antibiotics following intraoperative cultures
  - indications
    - no improvement after 24 hours of non-operative treatment
    - late presentation

TAG

(OBQ11.83) A 46-year-old homeless IV drug abuser presents with the hand infection shown in Figure A, which developed after sustaining a superficial laceration. Cultures are taken during operative irrigation and debridement, and he is started on antibiotic therapy. Based on the patients history, what is the most common pathogen in this setting? Topic

Review Topic

FIGURES: A

1. Herpes simplex virus
2. Candida albicans
3. Escherichia coli
4. Eikenella corrodens
5. Methicillin-resistant staphylococcus aureus

PREFERRED RESPONSE ▶

DISCUSSION: Figure A shows an abscess over the metacarpophalangeal joint of the thumb. Infections with these characteristics in IV drug abusers are most commonly caused by MRSA, and can affect any portion of the hand.

Imahara et al retrospectively reviewed 159 hand infections treated in the operating room over an 11-year period. The examined data included known risk factors for MRSA, including human immunodeficiency virus infection, diabetes mellitus, intravenous drug use, incarceration, and homelessness. Intravenous drug use was the only independent risk factor for CA-MRSA infections.

Boucher et al examined the trends in both nosocomial and community-associated MRSA infections and explored recent studies of the mechanisms that allow S. aureus to become resistant to currently available drugs.

Incorrect Answers:
1-Herpes simplex virus can cause Herpetic whitlow, as shown in Illustration A, typically presents on the fingers health care workers exposed to a carriers mouth. Usually, this infection appears as small ulcers or vesicles, and operative debridement is contraindicated.
2-Candida albicans is a more rare hand infection typically associated with chronic paronychia, as shown in Illustration B.
3-Escherichia coli is a less common cause of abscess formation in the hand.
4-Eikenella is usually associated with "fight-bite" infections on the dorsal aspect of the MCP joint, and does not commonly occur after superficial lacerations. It can also rarely occur in IV drug users who clean their needles with saliva, as Eikenlla is part of the normal oral flora. An example of a Eikenella infection is shown in Illustration C.

Illustrations: A

REFERENCES:

1. Imahara SD, Friedrich JB. Community-acquired methicillin-resistant Staphylococcus aureus in surgically treated hand infections. J Hand Surg Am. 2010 Jan;35(1):97-103. Epub 2009 Dec 4. PMID:19962836 (Link to Abstract)

2. Boucher HW, Corey GR. Epidemiology of methicillin-resistant Staphylococcus aureus. Clin Infect Dis. 2008 Jun 1;46 Suppl 5:S344-9. Review. PMID:18462089 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, John Badylak MD, Ben Taylor MD,

Please Rate Educational Value!

3.0

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TAG

(OBQ06.231) All of the following are considered the cardinal signs of flexor tenosynovitis EXCEPT: Topic

Review Topic

1. Tenderness along the flexor tendon sheath
2. Flexed resting posture of the finger
3. Fusiform swelling of the finger
4. Pain on passive extension of the finger
5. Pain on passive flexion of the finger

PREFERRED RESPONSE ▶

DISCUSSION: The hallmarks of pyogenic flexor tenosynovitis include 1) partially flexed resting posture of the involved finger, 2) pain with passive extension, 3) fusiform swelling of the finger, 4) volar tenderness along the flexor sheath (cardinal signs of Kanavel). Usually patients present after 24 or 48 hours of the onset of the symptoms. The standard of care is “urgent surgical drainage” to avoid tendon scarring or necrosis with subsequent impairment of finger function. According to Hand Surgery Update 3, open sheath irrigation has been replaced largely by closed sheath irrigation. These authors cite a retrospective study that showed no statistical difference in resolution of infection using open sheath irrigation or closed sheath irrigation, however, there was a trend towards more frequent complications and reoperations in the open drainage group. This infection generally requires admission, surgical I&D, followed by IV antibiotics and observation in-house.

Lille et al reviewed the records of 75 patients with pyogenic flexor tenosynovitis and found that there was no difference in outcomes between those who received intraoperative irrigation only versus those receiving intraoperative irrigation and continuous postoperative irrigation.

REFERENCES:

1. Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow, & Shoulder. Rosemont, IL., American Society for Surgery of the Hand 2003, pp 433-457

2. Lille S, Hayakawa T, Neumeister MW, et al: Continuous postoperative catheter irrigation is not necessary for the treatment of suppurative flexor tenosynovitis. J. Hand Surg Br 2000;25:304-307 PMID:10961561 (Link to Abstract)

Question Authors:

Greg Galano MD, Derek Moore, John Badylak MD,

Please Rate Educational Value!

3.0

Average 3.0 of 8 Ratings

Level of Evidence 4 (Case Series)

Lille S, Hayakawa T, Neumeister MW, et al: Continuous postoperative catheter irrigation is not necessary for the treatment of suppurative flexor tenosynovitis. J. Hand Surg Br 2000;25:304-307 PMID:10961561 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow, & Shoulder. Rosemont, IL., American Society for Surgery of the Hand 2003, pp 433-457

Undefined

Boucher HW, Corey GR. Epidemiology of methicillin-resistant Staphylococcus aureus. Clin Infect Dis. 2008 Jun 1;46 Suppl 5:S344-9. Review. PMID:18462089 (Link to Abstract)
Imahara SD, Friedrich JB. Community-acquired methicillin-resistant Staphylococcus aureus in surgically treated hand infections. J Hand Surg Am. 2010 Jan;35(1):97-103. Epub 2009 Dec 4. PMID:19962836 (Link to Abstract)

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