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https://upload.orthobullets.com/topic/6105/images/2167_f8[1]_moved.jpg
https://upload.orthobullets.com/topic/6105/images/w tendon sheaths.jpg
https://upload.orthobullets.com/topic/6105/images/variations.jpg
https://upload.orthobullets.com/topic/6105/images/pft1.jpg
https://upload.orthobullets.com/topic/6105/images/pft2.jpg
https://upload.orthobullets.com/topic/6105/images/tenosynovitis.jpg
Introduction
  • 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"
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 
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
  • Stiffness
  • Tendon or pulley rupture
  • Spread of infection
  • Loss of soft tissue
  • Osteomyelitis
 

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(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? Review Topic

QID: 3506
FIGURES:
1

Herpes simplex virus

1%

(19/2472)

2

Candida albicans

1%

(15/2472)

3

Escherichia coli

1%

(17/2472)

4

Eikenella corrodens

2%

(56/2472)

5

Methicillin-resistant staphylococcus aureus

95%

(2354/2472)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

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

QID: 242
1

Tenderness along the flexor tendon sheath

0%

(2/2640)

2

Flexed resting posture of the finger

1%

(20/2640)

3

Fusiform swelling of the finger

1%

(35/2640)

4

Pain on passive extension of the finger

5%

(130/2640)

5

Pain on passive flexion of the finger

92%

(2434/2640)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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