Review Question - QID 220006

This patient is presenting with flexor tenosynovitis (FTS) of the right long finger that has been present for more than one week. In the setting of FTS, delayed presentation warrants surgical intervention (Answer 1).

FTS is a clinical diagnosis that incorporates physical examination, imaging modalities, and laboratory analysis. Specific findings on physical examination of the involved finger are titled the Kanavel signs and include; fusiform swelling, resting in a flexed position, pain with passive extension of the finger, and tenderness along the flexor tendon sheath. The management of FTS can be both nonoperative or operative depending on several clinical factors and presentations. A trial of antibiotic treatment has been described for FTS if the patient presents early within the disease course. However, in cases of delayed presentation (>24 to 48 hours since symptom onset) and purulence, operative treatment is required.

Chapman et al. review the evaluation and treatment strategies of pyogenic flexor tenosynovitis (PFT). They state that PFT is a serious infection of the hand's flexor tendon sheath that can cause significant morbidity, including impaired function or amputation. Treatment typically involves prompt intravenous antibiotics and often surgical intervention, though no standardized surgical approach exists. They conclude that operative management includes a combination of surgical decompression and sheath irrigation, however, despite timely treatment, and regardless of the protocol used, complication rates remain high.

Kennedy et al. summarize the common presentations of PFT. They describe PFT as a serious infection of the flexor tendon sheath, diagnosed clinically using Kanavel’s four cardinal signs, though misdiagnosis is common, and delayed treatment can lead to severe complications such as tendon necrosis, deformity, and limb loss. Differentiating PFT from similar conditions like septic arthritis and crystal-induced arthritides is challenging due to overlapping symptoms. They conclude that Kanavel’s signs are a valuable diagnostic tool, but their absence does not reliably exclude PFT, emphasizing the need for cautious clinical judgment.

Giladi et al. completed a systematic review of the surgical management of acute PFT with variable use of systemic antibiotics. Their review revealed that incorporating antibiotic therapy led to excellent range of motion outcomes in 54% of patients. The authors conclude that early surgical management with catheter-based irrigation methods and systemic antibiotic therapy are interventions that are associated with improved functional outcomes.

Figure A is a clinical picture demonstrating a right long finger with fusiform swelling and resting in a flexed position.

Incorrect answers:
Answer 2: An immunocompromised status can predispose patients to rapidly evolving infections such as FTS/PFT, however, this is not a clinical variable that mandates surgical management.
Answer 3: The presence of all 4 Kanavel signs is an indication that a patient may have FTS but does not mandate surgical intervention if the patient presents early within their disease course and does not have expressible purulence on examination.
Answer 4: Advanced age does not mandate operative management if the patient presents early within the disease course and subsequently responds to systemic antibiotic therapy.
Answer 5: Malignancy can also lead to an immunocompromised state increasing the likelihood of developing infections such as FTS but does not mandate operative intervention.