Article

Cases of Early Infectious Flexor Tenosynovitis Treated Non-Surgically With Antibiotics, Immobilization, and Elevation

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Abstract

Background: Early infectious flexor tenosynovitis has been treated with urgent surgery by most surgeons since Bunnell wrote the first textbook of hand surgery in 1945. Some surgeons have good experience with non-surgical management of early presenting disease in some cases. Methods: This retrospective chart review included 12 inpatients with early infectious flexor synovitis who received conservative treatment with antibiotics, immobilization, and elevation without surgical drainage. Results: The mean time to resolution of infective symptoms for the 12 patients was 5 days (range: 2-11 days) for those receiving conservative management. Half of them required hand therapy. Eight of the 12 patients had good documentation of a full return of hand function. Conclusions: In some patients with early infectious flexor synovitis, urgent surgery may not be required. We present a brief synopsis of 12 such cases.

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... The expert evidence in the books and papers cited is simply reiterated from that era. The evidence for antibiotic therapy alone in the management of PFT is small and limited (Seiler [6], Stevanovic and Sharpe [7], McDonald [8], DiPasquale [9]) but is sufficient to suggest that surgery is not the only possibility and that high-quality surgical trials of surgery versus antibiotics would be of benefit. We aim to assess current opinions regarding the management of PFT to guide further education and research into this potentially devastating condition. ...
... The benefit of antibiotics without surgery was not reported on due to a lack of data. However, DiPasquale et al. [9] recently presented a case series of 12 patients in whom early PFT was treated successfully with intravenous antibiotics in combination with elevation and immobilization. ...
... Kanavel's signs may allow the clinician to differentiate between PFT and alternative hand infections such as herpetic whitlow, septic arthritis, paronychia, felons, cellulitis, crystal arthritides and tenosynovitis [11]. The classification of "early" is also a matter for discussion with some authors describing this as within 48 h of inoculation [11,12] whilst DiPasquale classifies early as "less than 3-7 days since the onset of symptoms" [9]. An alternative would be to consider staging of PFT according to severity. ...
Article
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Purpose Pyogenic flexor tenosynovitis (PFT) is recognized as a severe infection of the hand with potentially disastrous outcomes. The mainstay of treatment has been emergent surgical washout. Recent evidence suggests potential for conservative management with a combination of intravenous antibiotics, elevation and splinting. We aim to determine current management of PFT to guide further education and research. Method An electronic survey was distributed to attendees at the Pulvertaft Hand Trauma Symposium in May 2017. The survey was also sent to previous attendees. The survey was compiled by hand surgeons and piloted within a tertiary centre prior to dissemination. Questions focused on three clinical vignettes describing PFT of increasing severity. Responses were analyzed using Surveymonkey. Results A total of 91 clinicians responded. Almost 50% would proceed to surgical decompression and washout even in patients diagnosed early. This increased to 88% when treating a patient whose diagnosis was delayed. The majority of those advising surgery felt this should be within 24 h. More than 50% advocate active mobilization either immediately or as soon as possible regardless of severity. Almost all would use either general or regional anaesthesia and a two-incision technique with catheter irrigation. Conclusions Our survey demonstrates large variation in the management of PFT. Advice from the pre-antibiotic era continues to be followed with some clinicians continuing to advocate open surgery. There is substantial discrepancy regarding duration of immobilization. Further investigation into the management and outcomes of PFT is required to establish best practice guidelines for this rare but potentially devastating condition.
... From our data, 14 patients who underwent such a surgery had intraoperative findings not consistent with an established FSI. Similar situations are reported by others in the literature and have prompted suggestions for alternative treatment of some cases of FSIs [11][12]. One could argue that intravenous antibiotics, in addition to hand elevation and close observation, could still have been appropriate in these patients, avoiding the potential risks of surgical intervention. ...
... The original management of early flexor sheath washout stems from a preantibiotic era but is mainstay and focus of FSI treatment to this day. This view does appear to be changing, with greater varying opinions on the management for this condition [12]. It is well known that antibiotic use significantly improves the outcomes for FSI patients [5], and several groups have demonstrated through case series successful management of FSI patients with antibiotics alone, negating the need for surgery altogether in most cases [3,11,12]. ...
... This view does appear to be changing, with greater varying opinions on the management for this condition [12]. It is well known that antibiotic use significantly improves the outcomes for FSI patients [5], and several groups have demonstrated through case series successful management of FSI patients with antibiotics alone, negating the need for surgery altogether in most cases [3,11,12]. This alternative treatment does require a method to help risk-stratify patients to decide who requires surgery and who can be trialled with conservative methods. ...
Article
Flexor sheath infections (FSIs) are soft tissue infections affecting the hand, which, if mismanaged, can have devastating consequences. Clinical assessment is key to diagnosis, with many relying on Kanavel cardinal signs as an aid. To prevent unnecessary operative intervention and the associated post-operative combined patient and healthcare burden, it is key that patients with FSIs are correctly identified. It would also be useful to stratify severity of FSIs without surgical exploration. To date, there is no accepted method to assist clinicians in doing so. We retrospectively analysed data from a five-year period to see if we could identify pre-operatively (a) accurate predictors of FSIs and (b) severity of the FSIs. We established that only the presence of all four Kanavel cardinal signs significantly predicted the presence of an FSI. No other variable that was available prior to surgery could predict either presence or severity of infection.
... In der Literatur finden sich Hinweise darauf, dass eine intravenöse Antibiotikatherapie möglich sei, wenn die BSSI innerhalb von 48 Stunden entdeckt und behandelt wird. Die Hand muss dann aber engmaschig kontrolliert und, wenn sich keine Besserung innerhalb von 24 Stunden einstellt, operiert werden [7,17]. Rutenberg und Mitarb. ...
Article
Zusammenfassung Die Infektionen der Beugesehnenscheide gehören immer noch zu den gravierendsten und folgenschwersten Infektionen an der Hand. Wenn die typischen Kardinalzeichen einer Beugesehnenscheideninfektion nach Kanavel bestehen, sollte unverzüglich die Indikation zur Operation gestellt werden. Die Folgeschäden einer verzögerten oder verspäteten Operation mit enormen Bewegungseinschränkungen der Finger durch Zerstörung der Gleitschichten und massiven Verklebungen, die sich später häufig nur noch wenig durch Handtherapie verbessern lassen, sind so gravierend, dass sich konservative Therapieversuche nur sehr schwer rechtfertigen lassen. Das schnelle chirurgische Eingreifen und die frühzeitige Eröffnung und Entlastung sowie die Spülung der Sehnenscheide kann die Erkrankung, die Zerstörung der Gleitschichten sowie die starken Schmerzen fast augenblicklich beenden. Wichtig sind ein schnelles Erkennen und ein schnelles Handeln. Bei frühzeitiger Intervention kann häufig die normale Handfunktion komplett wiederhergestellt werden.
Article
Pyogenic flexor tenosynovitis is a frequent and serious condition. However, there is no consensus on the use of antibiotics. The objective of our study was to describe the treatment of this condition and to identify the surgical and medical management parameters to propose an effective and consensual postoperative antibiotic therapy protocol. We retrospectively reviewed pyogenic flexor tenosynovitis of the thumb or fingers treated between 01/01/2013 and 01/01/2018 at a teaching hospital. Inclusion criteria were confirmation of the clinical diagnosis intraoperatively and a minimum post-antibiotic follow-up of 6 months. Comorbidities, type of surgery, antibiotic therapy parameters, and treatment outcome were assessed. One hundred and thirteen patients were included. Fifty-four percent had comorbidities. The most frequent germ was staphylococcus, all patients received postoperative antibiotic therapy. Intravenous or intravenous followed by oral administration did not provide any benefit compared to an exclusively oral treatment (p = 0.46). The duration of postoperative antibiotic therapy (less than 7 days, between 7 and 14 days or more than 14 days) did not lead to any difference in healing rate (p = 0.67). However, treating for less than 7 days versus 7–14 days seemed to be associated with a higher risk of failure, although not statistically significant. Oral postoperative antibiotic therapy with amoxicillin + clavulanic acid for 7–14 days appears to be effective, allowing for outpatient management.
Article
Background: Treatment of pyogenic flexor tenosynovitis (FTS) historically involved surgical debridement supplemented with antibiotic therapy. No consensus exists on either: (1) the treatment algorithm for this infection; or (2) the clinical definition of “early” FTS. We performed a retrospective study to clarify indications for nonoperative management. Methods: We identified 40 patients with a diagnosis of FTS using Current Procedural Terminology and International Classification of Diseases, Tenth Revision, codes and a keyword search from an electronic medical record between 2011 and 2019. Patients underwent either surgical management (SG) (n = 20) or early antibiotics only (EAG) (n = 20). The surgical group was divided into patients with intraoperative purulence within the tendon sheath (PU) and those without purulence (NP). Results: The number of Kanavel signs and duration of days of symptoms were significantly greater in SG compared with EAG. Subgroup analysis of SG showed a greater number of days of symptoms in the NP group when compared with the PU group. No statistical significance was found with respect to age, smoking, or specific individual Kanavel signs between SG and EAG. Conclusions: Both duration of symptoms and number of Kanavel signs should be considered in suspected early FTS. Patients with shorter duration of symptoms and fewer Kanavel signs were treated successfully with antibiotics alone. Operatively confirmed FTS presented more acutely with fewer days of symptoms and a higher number of Kanavel signs. Patients with subacute presentations may represent inflammatory conditions and hand infections other than FTS.
Article
Zusammenfassung Hintergrund/Ziel Die septische Tenosynovialitis der Beugesehnenscheiden erfordert eine dringliche Behandlung, um Sehnennekrosen und den Verlust von Fingern zu verhindern. Gegenstand des vorliegenden Artikels ist die Behandlung durch Revision und postoperativ kontinuierliche Spülung über eine geschlossene Spül-Saug-Drainage. Patienten und Methoden Vom 1.1.2007 bis zum 31.12.2016 wurden 54 Patienten mit septischer Tenosynovialitis einer Beugesehnenscheide mit einer Spül-Saug-Drainage behandelt. Zusätzlich zur Auswertung der Krankenakten (betroffener Finger, betroffene Hand, Dauer des stationären Aufenthaltes, notwendige Revisionsoperationen) konnten 33 Patienten (19 Männer und 14 Frauen) mit einem Durchschnittsalter von 51 (8–85) Jahren nach durchschnittlich 21 (4–38) Monaten nachuntersucht werden. Dabei wurden die Beweglichkeit des betroffenen Fingers/Daumens (Abstand der Fingerkuppe zur distalen Hohlhandbeugefurche beim Faustschluss, resp. der Kapandji-Index), die Grobkraft/Spitzgriffkraft prozentual zur unverletzten Gegenseite, die Schmerzen mittels numerischer Ratingskala (NRS) und der DASH-Score erfasst. Das Gesamtergebnis wurde mittels des Bewertungsschemas von Buck-Gramcko für Beugesehnenrekonstruktionen beurteilt. Ergebnisse Der Krankenhausaufenthalt dauerte im Durchschnitt 9 (3–26) Tage. Elfmal war eine Revision erforderlich, 3-mal davon eine Neuanlage der Spül-Saug-Drainage, 2-mal eine Strahlresektion und einmal eine Amputation in Höhe des Mittelgelenkes. Die nachuntersuchten Patienten wiesen im Mittel eine Grobkraft von 84 (23–163) % der nicht betroffenen Gegenseite auf. Der Ruheschmerz betrug durchschnittlich 0,2 (0–4), der Belastungsschmerz 1,2 (0–8) auf der NRS, der DASH-Score 16,8 (0–58) Punkte. Nach dem Bewertungssystem für Beugesehnenfunktionen war ein Ergebnis unbefriedigend, eines befriedigend, 5 gut und 26 sehr gut. Schlussfolgerungen Die kontinuierliche Spülung über eine Spül-Saug-Drainage bei der septischen Tenosynovialitis der Beugesehnenscheiden ist ein erfolgreiches Verfahren mit niedriger Amputationsrate. Die funktionellen Ergebnisse sind überwiegend gut und sehr gut.
Article
Background: Pyogenic flexor tenosynovitis (PFT) has been considered a surgical emergency. Varying operative approaches have been described, but there are limited data on the method, safety, and efficacy of nonoperative or bedside management. We present a case series where patients with early flexor tenosynovitis are managed using a limited flexor sheath incision and drainage (I&D) in the emergency department (ED) to both confirm purulence within the flexor sheath and as definitive treatment. Methods: A retrospective study of all patients clinically diagnosed in the ED with flexor tenosynovitis at our institution from 2012 to 2019 was performed. Patients with frank purulence on examination were taken emergently to the operating room (OR). Patients with equivocal findings underwent limited flexor sheath I&D in the ED. Safety and efficacy were studied for patients with early flexor tenosynovitis managed with this treatment approach. Results: Thirty-four patients met the inclusion criteria. Ten patients underwent direct OR I&D, and 24 patients underwent ED I&D. In the ED I&D group, 96% (24 of 25) of patients did not have frank purulence in the flexor sheath and were managed with bedside drainage alone. There were no procedural complications and no need for repeat operative intervention. Time to intervention (3.1 hours vs 8.4 hours) was significantly shorter for the ED I&D group compared with the OR I&D group. Within the ED I&D group, 86% of patients exhibited good/excellent functional scores. Conclusions: Limited flexor sheath I&D in the ED provides a potential safe and effective way to manage patients with early flexor tenosynovitis.
Article
Pyogenic flexor tenosynovitis is a closed-space infection that can lead to a devastating loss of finger and hand function. It can spread rapidly into the palm, distal forearm, other digits, and nearby joints. Healthy individuals may present with no signs of systemic illness and often deny any penetrating trauma or inoculation. Early diagnosis and prompt treatment are required to preserve the digit and prevent morbidity and loss of hand function. Many treatment options have been described, although all share 2 common principles: evacuation of the infection and tailored postoperative antibiotic treatment with close monitoring to ensure clinical improvement.
Article
While many hand infections are superficial, diligent evaluation, diagnosis, and treatment of these infections are central for preventing disability and morbidity. Maintaining a wide differential diagnosis is important as some hand infections may mimic others. In geographic areas with more than a 10% to 15% prevalence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) hand infections, empiric antibiotics should adequately cover MRSA. Once culture results are available, antibiotic regimens should be narrowed to reduce the development of resistant pathogens.
Article
Pyogenic flexor tenosynovitis (PFT) of the hand is a common infection which is clinically diagnosed using Kanavel's signs. Delay in diagnosis and treatment may lead to devastating outcomes, including reduced range of motion (ROM), deformities, tendon impairment or even amputation. While the gold standard for treatment is irrigation and debridement of the flexor sheath, little is known about the outcomes of conservative treatment with intravenous (IV) antibiotics. Patients treated conservatively for PFT between 2000 and 2013 were included. Demographic information, co-morbidities and clinical features at presentation such as Kanavel's signs and inflammatory markers levels were gathered. Treatment course, length of stay (LOS), functional outcomes and complications were collected. Fifty-four (54) patients presented with PFT in the study period. Forty-six (46) patients, ages 19–84 years old, who were treated conservatively were included. Average time from symptoms onset to presentation was 4.6 ± 7.1 days. Fourteen (14) patients failed to improve with course of oral antibiotics prior to presentation. The average number of Kanavel's signs was 3 ± 0.7. Inflammatory markers were elevated in 82.2% of patients. The mean LOS was 4.7 ± 2 days. Forty-four (44) patients continued follow-up for 55 ± 45 months. Final flexion ROM was full or minimally limited in 69% of patients. Three patients were eventually operated. Complication rate for the entire cohort was 4.3% and no fingers were lost. This retrospective case series indicate that inpatient empirical IV antibiotic therapy can be considered for patients presenting with uncomplicated PFT, provided it is practiced under a hand specialist’s surveillance.
Article
Purpose: Characteristic swelling has been described as a differentiating sign of pyogenic flexor tenosynovitis (PFT) but has not been validated. We conducted a retrospective study of adults with finger infections to compare radiographic parameters of soft tissue dimensions. Our hypothesis was that in patients with digit infections, radiographic soft tissue thickness measurement would differ between PFT and non-PFT infected digits. Methods: Patients with a finger infection and radiographic evaluation were identified retrospectively at a large academic medical center and divided into 2 groups: PFT (n = 31) and non-PFT infections (n = 31). We defined PFT as purulence in the tendon sheath or positive culture growth from the sheath at surgery. Non-PFT infections included all other finger infections such as abscesses and cellulitis. A total of 15 radiographic measurements were made on all included digits. Ratios and differences were calculated to characterize the pattern of swelling for each infected finger. Bivariate analysis was performed to identify potential predictor variables between the PFT and non-PFT groups. Logistic regression was performed to reduce confounding and model potential relationships. Results: Neither presence of diffuse swelling nor the shape of finger swelling distinguished PFT from non-PFT infections. All finger infections resulted in diffuse swelling. Pyogenic flexor tenosynovitis was distinguished by differential volar soft tissue thickness minus dorsal soft tissue thickness on radiographs at the proximal phalanx level (9 ± 1 mm for PFT vs 5 ± 1 mm for non-PFT). This was an independent predictor of PFT. The area under the receiver operating curve was 0.83 (95% confidence interval, 0.73-0.94). A difference between volar and dorsal soft tissue swelling of 7 mm or greater had a positive predictive value of 82% with a sensitivity of 84% and specificity of 74%. A difference of 10 mm predicted PFT infection with 76% probability (95% confidence interval, 73% to 99%). Conclusions: Pyogenic flexor tenosynovitis may result in uniform finger swelling, but this does not appear to distinguish PFT from other finger infections. Acute PFT swelling is distinguished by differential volar versus dorsal radiographic soft tissue thickness at the level of the proximal phalanx. The term "fusiform swelling" is a misnomer for the appearance of acute PFT because the finger is not spindle-shaped. Type of study/level of evidence: Diagnostic IV.
Article
Pyogenic flexor tenosynovitis (PFT) is an aggressive closed-space infection that can result in severe morbidity. Although surgical treatment of pyogenic flexor tenosynovitis has been widely described, the role of antibiotic therapy is inadequately understood. We conducted a literature review of studies reporting on acute pyogenic flexor tenosynovitis management. A total of 28 case series articles were obtained, all of which used surgical intervention with varied use of antibiotics. Inconsistencies among the studies limited summative statistical analysis. Our results showed that use of antibiotics as a component of therapy resulted in improved range of motion outcomes (54% excellent vs. 14% excellent), as did using catheter irrigation rather than open washout (71% excellent vs. 26% excellent). These studies showed benefits of early treatment of pyogenic flexor tenosynovitis and of systemic antibiotic use. As broad-spectrum antibiotics have changed the management of other infectious conditions, we must more closely evaluate consistent antibiotic use in pyogenic flexor tenosynovitis management. Level of Evidence: Therapeutic, Level III. © The Author(s) 2015.
Article
Flexor tenosynovitis is an aggressive closed-space infection of the digital flexor tendon sheaths of the hand. We present a case of pyogenic flexor tenosynovitis in an immunocompromised patient and discuss the importance of early diagnosis and referral to a specialist hand surgery unit. A 61-year-old man visited his general practitioner because of swelling and tenderness of his left index finger. The patient was discharged on oral antibiotics but returned 4 days after because of deterioration of his symptoms and was referred to a plastic surgery unit. A diagnosis of flexor tenosynovitis was made and the patient required multiple debridements in theatre, resulting in the amputation of the infected finger. Pyogenic flexor tenosynovitis is a relatively common but often misdiagnosed hand infection. Patients with suspected flexor tenosynovitis should be referred and treated early to avoid significant morbidity, especially when risk factors for poor prognosis are present.
Article
Flexor tendon sheath infections of the hand must be diagnosed and treated expeditiously to avoid poor clinical outcomes. Knowledge of the sheath's anatomy is essential for diagnosis and to help to guide treatment. The Kanavel cardinal signs are useful for differentiating conditions with similar presentations. Management of all but the earliest cases of pyogenic flexor tenosynovitis consists of intravenous antibiotics and surgical drainage of the sheath with open or closed irrigation. Closed irrigation may be continued postoperatively. Experimental data from an animal study have shown that local administration of antibiotics and/or corticosteroids can help lessen morbidity from the infection; however, additional research is required. Despite aggressive and prompt antibiotic therapy and surgical intervention, even otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection. Patients with medical comorbidities or those who present late with advanced infection can expect poorer outcomes, including severe digital stiffness or amputation.
Article
We describe a surgeon, nursing, and patient-friendly method of treating acute pyogenic tenosynovitis using a 2-incision, closed sheath irrigation method and postoperative usage of a continuous marcaine ON-Q pain pump. The advantages of this technique include the ease of catheter placement intraoperatively and the use of a smaller diameter tubing within the flexor sheath. In addition, this technique eliminates the need for nursing staff to perform irrigation, and most importantly, the technique results in improved postoperative pain control allowing an early aggressive postoperative therapy protocol. We retrospectively reviewed 9 patients with an average age of 42.8 years (range: 20 to 66 y) who presented with acute pyogenic flexor tenosynovitis. All patients underwent surgery on the day of presentation to us with the described technique with the catheter left in place for 2 days. Outcome measurements included length of hospital stay, final range of motion, recurrence of infection, and complications. Average hospital stay was 2.8 days (range: 2 to 6 d). There were no recurrent infections. Seven patients regained full total active motion of the involved digit. The 2 patients with incomplete recovery of digital motion regained 125 and 105 degrees of total active motion, respectively. In addition, there were 3 minor complications including cold intolerance (2 patients) and local skin necrosis that responded to local wound care (1 patient). This novel method of managing acute flexor tenosynovitis seems to be safe, effective, and very friendly for surgeons, nurses as well as patients. Intraoperative pearls for catheter placement using a 22-guage wire inside a musical sharp5 pediatric French feeding tube are also described.
  • Grinnell RS