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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)