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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
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