Duke Orthopaedics
Wheeless' Textbook of Orthopaedics

Infectious Flexor Tenosynovitis

- See:
      - Hand Infections - Menu
              - Kanavel's signs
              - Thumb Flexor Sheath Infections
              - Workup and Treatment

- Relevant Anatomy:
    - index, long, & ring tendon sheaths of most hands extend from terminal phalanges to a point just distal to superficial palmar arch;
           - occassionally they may extend to the wrist;
           - proximal ends of flexor sheaths overlie distal ends of thenar and midpalmar spaces;
    - thumb tendon sheath communicates w/ the radial bursa;
    - little finger tendon sheath (sometimes  third & fourth sheaths) will extend to and communicate with ulnar bursae;
    - radial & ulnar bursae communicate proximal to the carpal tunnel in 50-80% of patients;
          - accounts for horse shoe tenosynovitis;
          - horse shoe abscess are drained by a combination of incisions into little finger (ulnar bursae and radial bursa incisions);
    - lumbrical muscle sheaths
    - mid palmar space
    - paron's space

- Exam:
    - Kanavel's signs
          - goal is to distinguish infectious tenosynovitis from superficial or localized abscess (see felon);
          - pain w/ finger extension may be the earliest sign present;
    - look for signs of direct penetration, esp at flexor creases;
          - in cases, where signs of direct innoculation are not present, consider neiserria tenosynovitis;

- Laboratory Considerations:
    - bacteriology of hand infections
    - gram stain:
          - gram negative bacilli
          - gram negative cocci
          - gram positive bacilli
          - gram positive bacilli

- Non Operative Treatment:
    - infectious tenosynovitis is a true orthopaedic emergency and in most cases immediate drainage in the OR is required;
    - if infectious tenosynovitis is diagnosed within 24 to 48 hrs of onset of symptoms, it may also be treated w/ antibiotics, along w/ splinting and hand elevation;
           - note, however, that operative treatment is usually required;
    - antibiotic treatment based on organism:

- Surgical Treatment:
    - if there is no dramatic improvment after 24 hrs of antibiotics or if injury is more than 48 hours old, surgical drainage is indicated;
    - if tendon sheath infection is seen late or is not treated properly early, skin loss, tendon necrosis, & subsequent osteomyelitis can result;
    - closed suction drainage:
           - is a commonly used form of treatment, but is high maintenance, and is uncomfortable for the patient;
           - many surgeons prefer immediate open draninage;
    - open drainage:
           - if infection has gotten out of control, closed irrigation is not be possible;
           - in this case open drainage may be required;
           - posterolateral finger incision has the advantage of being able to loosely cover the flexor tendons postop (as opposed to zig-zag incisions which tend to gap open and expose the tendons to dissication)

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Thursday, August 23, 2012 10:55 am

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