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Pyogenic flexor tenosynovits (Definition (Infection of the synovial sheath…
Pyogenic flexor tenosynovits
Definition
Infection of the synovial sheath that surrounds the flexor tendon
Orthopaedic emergency
Epidemiology
Incidence: 2.5 - 9.4% of all hand infections
Aetiology
Risk factors: diabetes, IV drug use, immunocompromised patients
Microbiology
Staph aureus: 45-70% (most common)
MRSA: 29% (seen in IV drug users)
Other microbes include pasteurella (animal), eikenella (human bite), etc.
Pathophysiology
Causes
Direct spread from felon (finger tip infection), septic joint, deep space infection, etc.
Penetrating trauma to the tendon sheath e.g. animal bites
Leads to septic and pressure driven necrosis --> destruction of tendon and surrounding structures
Clinical presentation
Symptoms
Pain
Swelling
Present over 24 -48 hours
Usually locatised to palmer aspect of 1 digit
Warmth
Erythema
+/- fever
Signs: Kanaval signs
Flexed posturing of digit
Tenderness to palpation
Marked pain with passive extension
fusiform swelling of the digit
Investigations
X-ray: may help rule out foreign body/bony involvement , usually normal
MRI/US: useful to confirm presence of tendon sheath abnormalities and pre-op evaluation
Blood cultures
Management
Non-operative (rare)
IV Abx, hospital admission, observation, immobilisation
Indications: early presentation, if sx improve over 24 hours no surgery required
Operative
Incision and drainage followed by culture specific IV Abx
Low threshold to operate, indicated in late presentations
Prognosis
Complications
Osteomyelitis
loss of spft tissue
boutenneire deformity
Amputation
Tendon or pulley rupture
Spread of infection
Stiffness
Generally considered to have a poor prognosis
