Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Please confirm action

You are done for today with this topic.

Would you like to start learning session with this topic items scheduled for future?

Updated: Apr 6 2022

Pyogenic Flexor Tenosynovitis

  • summary
    • Pyogenic flexor tenosynovitis is an infection of the synovial sheath that surrounds the flexor tendon.
    • Diagnosis is made clinically with the presence of the 4 Kanavel signs.
    • Treatment is urgent irrigation and debridement of the flexor tendon sheath with IV antibiotics.
  • Epidemiology
    • Incidence 
      • 2.5 to 9.4% of all hand infections
    • Risk factors
      • diabetes
      • IV drug use
      • immunocompromised patients
  • Etiology
    • Pathophysiology
      • mechanism
        • penetrating trauma to the tendon sheath
        • direct spread from
          • felon
          • septic joint
          • deep space infection
      • pathoanatomy
        • infection travels in the synovial sheath that surrounds the flexor tendon
      • microbiology
        • Staph aureus (40-75%)
          • most common
        • MRSA (29%)
          • intravenous drug abusers
        • other common skin flora
          • staph epidermidis
          • beta-hemolytic streptococcus
          • pseudomonas aeruginosa
        • mixed flora and gram negative organsims
          • in immunocompromised patients
        • Eikenella
          • in human bites
        • Pasteurella multocida
          • in animal bites
    • Associated conditions
      • "horseshoe abscess"
        • may develop from spread pyogenic flexor tenosynovitis
          • of 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 a "horseshoe abscess"
  • Anatomy
    • Tendon sheaths
      • function
        • to protect and nourish the tendons
      • anatomy
        • variations common
        • sheaths extends from
          • index, middle, and ring fingers
            • from DIP to just proximal to A1 pulley
          • thumb (flexor pollicus longus sheath)
            • from IP joint to as proximal as radial bursa (in wrist)
          • little finger
            • from DIP joint to as proximal as ulnar bursa (in wrist)
  • Presentation
    • Symptoms
      • pain and swelling
        • typically present in delayed fashion (over 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, but may be useful to rule out foreign object
    • MRI
      • cannot distinguish infectious flexor tenosynovitis from inflammatory but may help determine the extent of the ongoing process
  • Differential
    • Felon
    • Cellulitis
    • Deep space infection
    • Collar button infection
  • Diagnosis
    • Clinical
      • diagnosis is made with careful history and physical examination (Kanavel signs)
  • Treatment
    • Nonoperative (rare)
      • hospital admission, IV antibiotics, hand immobilization, observation
        • indications
          • early presentation
        • modalities
          • splinting
        • outcomes
          • if signs of improvement within 24 hours, no surgery is required
    • Operative
      • I&D followed by culture-specific IV antibiotics
        • indications
          • low threshold to operative once suspected (orthopaedic emergency)
          • late presentation
          • no improvement after 24 hours of non-operative treatment (confirmed diagnosis)
        • technique (see below)
  • Technique
    • I&D of flexor tendon
      • approach
        • full open exposure using long midaxial or Bruner incision
        • two small incisions placed distally at A5 pulley and proximally at A1 pulley and using an angiocatheter
  • Complications
    • Tendon or pulley rupture
    • Spread of infection
    • Loss of soft tissue
    • Osteomyelitis
1 of 13
1 of 7
Private Note

Attach Treatment Poll
Treatment poll is required to gain more useful feedback from members.
Please enter Question Text
Please enter at least 2 unique options
Please enter at least 2 unique options
Please enter at least 2 unique options