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  • Infection of the synovial sheath that surrounds the flexor tendon
  • Epidemiology
    • incidence 2.5 to 9.4% of all hand infections
    • risk factors
      • diabetes
      • IV drug use
      • immunocompromised patients
  • 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"
  • 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)
  • 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
  • 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 
  • 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)
  • 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
  • Stiffness
  • Tendon or pulley rupture
  • Spread of infection
  • Loss of soft tissue
  • Osteomyelitis

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