flexor tendon sheath infections

Flexor Tendon Sheath Infectionsof the Hand

Abstract

Flexor tendon sheath infections of the hand must be diagnosedand treated expeditiously to avoid poor clinical outcomes.Knowledge of the sheath’s anatomy is essential for diagnosis andto help to guide treatment. The Kanavel cardinal signs are usefulfor differentiating conditions with similar presentations.Management of all but the earliest cases of pyogenic flexortenosynovitis consists of intravenous antibiotics and surgicaldrainage of the sheath with open or closed irrigation. Closedirrigation may be continued postoperatively. Experimental data froman animal study have shown that local administration of antibioticsand/or corticosteroids can help lessen morbidity from the infection;however, additional research is required. Despite aggressive andprompt antibiotic therapy and surgical intervention, even otherwisehealthy patients can expect some residual digital stiffness followingflexor tendon sheath infection. Patients with medical comorbiditiesor those who present late with advanced infection can expectpoorer outcomes, including severe digital stiffness or amputation.

Flexor tendon sheath infections ofthe hand can be devastating. Prior

to the advent of antibiotic therapy, suchinfections led to morbidity, includingloss of limb or life. Good functional re-sults have been achieved with closedtendon sheath irrigation and postoper-ative treatment using continuous closedirrigation systems.1-4 However, nearlya century after Kanavel’s seminal workon the subject,5 patients with pyogenicflexor tenosynovitis (PFT) remain atrisk of great morbidity (eg, digit stiff-ness, amputation) despite modern an-tibiotic and surgical treatment.

Anatomy

Accurate diagnosis and management,particularly surgical management, offlexor tendon sheath infections re-quires an understanding of the anat-

omy involved. Several variations offlexor tendon sheath anatomy havebeen reported6 (Figure 1). Distal ter-mination of the sheath of each fingeris at the bony insertion of the flexordigitorum profundus (FDP) tendon.In the thumb, the sheath terminatesat the flexor pollicis longus (FPL)tendon.

Typically, the proximal extent ofthe sheaths of the index, middle, andring fingers lies just proximal to theA1 pulley.6,7 The FPL sheath extendsproximally as the radial bursa to ap-proximately 2.5 cm proximal to thewrist flexion crease.8 Phillips et al9

and Scheldrup6 reported that theflexor tendon sheath of the little fin-ger communicated proximally withthe ulnar bursa in 32% and 80% ofpatients in their series, respectively.

In the palm, the ulnar bursa sur-rounds the FDP and flexor digitorum

Reid W. Draeger, MD

Donald K. Bynum, Jr, MD

From the Department ofOrthopaedics, University of NorthCarolina School of Medicine, ChapelHill, NC.

Dr. Draeger or an immediate familymember has stock or stock optionsheld in GlaxoSmithKline. NeitherDr. Bynum nor any immediate familymember has received anything ofvalue from or owns stock in acommercial company or institutionrelated directly or indirectly to thesubject of this article.

J Am Acad Orthop Surg 2012;20:373-382

http://dx.doi.org/10.5435/JAAOS-20-06-373

Copyright 2012 by the AmericanAcademy of Orthopaedic Surgeons.

Review Article

June 2012, Vol 20, No 6 373

superficialis tendons of the index,long, and ring fingers, although thebursa is not commonly contiguouswith the sheaths of these digits dis-tally.6,7 Proximally, the ulnar bursaextends to the same level as and iscontiguous with the radial bursa inapproximately 80% of persons.6,7

This explains formation of a horse-shoe abscess in which an infection inthe small finger tracks into the palmand out to the thumb, or vice versa.

The digital flexor tendon sheath iscomposed of retinacular (pulley) andsynovial (membranous) tissue. Thepulley system is composed of trans-verse (palmar aponeurosis pulley),annular (A1-A5), and cruciform or

cruciate (C1-C3) pulleys10,11 (Figure2). A2 and A4 are the broadest pul-leys; during surgical drainage in pa-tients with PFT, sectioning of thesepulleys should be avoided to mini-mize the risk of tendon bowstring-ing. The narrower annular and thecruciform pulleys accommodate fin-ger flexion without buckling of thepulley system or impingement of theflexor tendons.7

The thumb has two annular pul-leys, A1 and A2, with a broad, thickoblique pulley between them (Figure3). When draining infections of theflexor tendon sheath of the thumb,sectioning of the oblique pulley mustbe avoided to prevent iatrogenic loss

of interphalangeal joint extensioncaused by bowstringing.7

The synovial portion of the sheathis a double-walled tube that is con-sidered a closed anatomic space. Thetube is composed of an inner viscerallayer, or epitenon, and an outer pari-etal layer, which is reinforced bythickening of the retinacular pul-leys.7,12 The synovial portions of thesheath are visible in the spaces be-tween the pulleys. The visceral andparietal layers are contiguous at theproximal cul-de-sac (ie, the proximalorigin of the sheath), the vinculae,and the distal extension of thesheath.12 A synovial space is locatedbetween the two layers and becomes

Illustration demonstrating the anatomic variations of the flexor tendon sheath and bursa patterns of the hand as well astheir relative frequency. (Reproduced with permission from Doyle JR, Botte MJ: Hand, in Doyle JR, Botte MJ, eds:Surgical Anatomy of the Hand and Upper Extremity. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, p 605.)

Figure 1

Flexor Tendon Sheath Infections of the Hand

374 Journal of the American Academy of Orthopaedic Surgeons

distended under pressure with an in-fection. Pressure in the sheath can re-sult in the spread of infection intoneighboring bursae and fascialspaces within the hand and may ex-tend into the forearm through theParona space (ie, the potential spacebetween the flexor tendons and thepronator quadratus).

The nutrition that the flexor ten-dons rely on is provided via the ex-trinsic blood supply through the vin-culae and diffusion through thesynovial fluid. PFT has been foundto markedly increase pressure in thesheath, sometimes exceeding 30 mmHg, and may lead to tendon necrosisvia inhibition of extrinsic blood

flow.13 Consequently, prompt drain-age and decompression of the sheathare critical.

Infectious Epidemiology

Although hematogenous seeding ofthe flexor tendon sheath is possible,PFT is typically caused by a puncturewound.1,14,15 Given this mechanismof injury, skin flora, most commonlyStaphylococcus aureus, was found in40% to 75% of positive cultures inseveral series.1-3,14,16-19 Methicillin-resistant S aureus (MRSA) has beenfound in up to 29% of cases in severalseries and must be considered when de-

termining appropriate preculture anti-biotic treatment.19-21 Other com-monly isolated bacteria include Sepidermidis, β-hemolytic Streptococ-cus species, and Pseudomona aerugi-nosa.20,22 Infections with mixed floraor Gram-negative rods are also com-mon in immunocompromised pa-tients; therefore, presumptive antibi-otic coverage should be broad. Inone recent series, mixed flora infec-tions were found in 36 of 61 patients(59%), with 26% of cultures demon-strating mixtures of anaerobic andaerobic organisms.3 Rarely, PFT canbe caused by Eikenella corrodensfrom a human bite or Pasteurellamultocida from an animal bite.20

Other rare causes of PFT include

Illustration of the thumb pulleysystem. The annular pulleys of thethumb, A1 and A2, overlay themetacarpophalangeal andinterphalangeal joints, respectively.The oblique pulley overlies theproximal phalanx and runsobliquely from its proximal origin onthe ulnar aspect of the proximalphalanx to a distal insertion on theradial aspect of the proximalphalanx. (Redrawn with permissionfrom Zissimos AG, Szabo RM,Yinger KE, Sharkey NA:Biomechanics of the thumb flexorpulley system. J Hand Surg Am1994;19[3]:475-479.)

Figure 3

Illustrations of the pulley system of the finger. A, The palmar aponeurosispulley (PA), A2, and A4 overlie the metacarpal, proximal phalanx, and middlephalanx, respectively. The narrower A1 and A3 pulleys are located over themetacarpophalangeal and proximal interphalangeal joints, respectively. Thenarrowest of the annular pulleys, A5, extends to the distal interphalangealjoint. The cruciform pulleys, C1, C2, and C3, are located at the distal end ofthe A2 pulley, between A3 and A4, and at the distal end (or sometimes as anextension) of the A4 pulley, respectively. B, The two fibrous layers of A2 aredemonstrated, with the annular fibers of the pulley overlaid by oblique fibersthat coalesce at the distal end of the pulley to form C1. (Redrawn withpermission from Doyle JR: Anatomy of the flexor tendon sheath and pulleysystem: A current review. J Hand Surg Am 1989;14[2]:349-351.)

Figure 2

Reid W. Draeger, MD, and Donald K. Bynum, Jr, MD

June 2012, Vol 20, No 6 375

Listeria monocytogenes, which hasbeen identified in farm workers,23

Clostridium difficile, which wasfound in patients with a previouslytreated infection elsewhere,24 andNeisseria gonorrhoeae, which wasreported in sexually active adoles-cents in the setting of disseminatedgonococcal infection.25

Culture-negative cases of PFT arealso common and have been re-ported in 20% to 63% of cases inseveral studies.1-3,14,16-19 Cultures maybe negative as a result of presump-tive antibiotic treatment or a vigor-ous immune response. Presumptivetreatment should include broad-spectrum antibiotics to treat bothGram-positive cocci and Gram-negative rods. Institutional and localantibiotic resistance patterns of bac-teria should guide treatment. Rou-tine presumptive coverage at our in-stitution includes an intravenous (IV)antibiotic that covers MRSA, givenits high prevalence as a causative or-ganism of PFT.

In patients with indolent clinicalcourses, mycobacterial infection

should be suspected. Mycobacteriummarinum should be considered in thepatient with a puncture wound sus-tained in a marine setting. Mkansasii is the second most commonmycobacterial isolate in persons withchronic atypical mycobacterial syno-vitis.26 Bacteria may take 6 weeks togrow in culture, delaying definitivediagnosis; therefore, presumptive an-tibiotic treatment is needed whenmycobacterial infection is sus-pected.27 Intraoperatively, exuberantsynovitis is encountered and may re-quire complete synovectomy to dé-bride the infected tissue.27

Diagnosis

Prompt diagnosis of PFT is essentialto institute effective treatment. Inour experience, patients with PFThave a history of penetrating traumato the hand 2 to 5 days before pre-sentation, but immunocompromisedpatients may present even later.Close examination of the hand mayreveal cuts, scratches, or puncture

wounds. The presence and timing ofseeding trauma can be helpful inguiding management of the infection.

Diagnosis of PFT is primarily clinical.Radiographs of the hand are obtainedto rule out bony trauma or the presenceof a retained foreign body. Typically,MRI and ultrasonography are unnec-essary for diagnosis. Laboratory testssuch as erythrocyte sedimentation rateand C-reactive protein level are non-specific and unhelpful for initial diag-nosis, but they may be useful if mon-itored over time to gauge response totreatment.

Kanavel5 described four cardinalsigns that characterize infection ofthe flexor tendon sheath. These signsinclude symmetric swelling of the en-tire digit, exquisite tenderness alongthe course of the tendon sheath, adigit with a semiflexed posture, andpain with attempted passive exten-sion of the digit. These signs havebeen widely used as diagnostic crite-ria for PFT (Figure 4). Clinical expe-rience has shown that these clinicalsigns are useful for diagnosis of PFT;however, no studies have validatedtheir sensitivity and specificity. In astudy of 75 patients with PFT, Panget al17 found that fusiform swellingwas most often present (97% of pa-tients), followed by pain on passiveextension (72%), semiflexed digitposture (69%), and tenderness alongthe flexor tendon sheath (64%). In aretrospective review of 41 patientswith PFT, Dailiana et al19 reportedthat all patients had tenderness alongthe flexor tendon sheath and painwith passive extension. However,only 22 of 41 patients (54%) exhib-ited all four Kanavel cardinal signs.Neviaser and Gunther28 reportedthat the most reliable Kanavel sign ispain on passive extension of thedigit. They also found that the in-ability to flex the finger to touch thepalm was another clinical sign ofPFT. We agree with others who havesuggested that tenderness along the

A, Clinical photograph of the right hand demonstrating pyogenic flexortenosynovitis (PFT) of the index finger. Note the fusiform swelling andpartially flexed posture of the digit. B, Clinical photograph of the left hand ofa patient with advanced PFT demonstrating subcutaneous purulence andlocal ischemia in addition to fusiform digital swelling. (Courtesy of RobertStrauch, MD, New York, NY.)

Figure 4



flexor tendon sheath that may ex-tend into the palm is a valuable clini-cal sign that can be used to differen-tiate PFT from other conditions (eg,herpetic whitlow, septic arthri-tis).14,15,26 These conditions may clini-cally resemble infections of the flexortendon sheath in the hand; however,patients with these conditions oftenlack Kanavel signs.

A thorough history is also impor-tant for diagnosis of PFT. Patientswith medical comorbidities such asdiabetes mellitus or IV drug use, orthose with compromised immunesystems, may not exhibit Kanavelsigns as dramatically as those withhealthy immune systems.

Differential Diagnosis

Herpetic WhitlowHerpetic whitlow is a rare clinicalentity that represents a cutaneous in-fection with herpes simplex virus andis most often found in medical anddental professionals. Patients reportpain in the affected digit, typically atthe distal tip of the finger, and oftenhave painful, clear, fluid-filled vesi-cles, which may coalesce into painfulbullae (Figure 5). Acyclovir or simi-lar antiviral agents can be used tomanage the infection; surgical drain-age of the vesicles should be avoidedbecause it can lead to systemic dis-semination of a localized infection orbacterial superinfection of the site.15

Septic ArthritisSeptic arthritis of an interphalangealor metacarpophalangeal joint pre-sents as localized pain, swelling, anderythema about the infected joint.Active or passive motion at the jointelicits exquisite pain. The joint maybe held in partial flexion in an at-tempt to lessen painful tension onthe joint capsule. Patients with septicarthritis lack the fusiform digitalswelling and pain along the entire

course of the tendon sheath associ-ated with PFT.

Crystal-induced Arthritidesand TenosynovitisGout and pseudogout flares of thehand joints can present as localizedpain at the involved joint or swellingabout the length of the affected digit.Clinically, these patients lack painalong the course of the flexor tendonsheath, often do not have the painwith passive stretch to the extent as-sociated with PFT, and typically lacka partially flexed posture in the af-fected digit. In general, these patientsexperience less severe pain in the in-volved joints with active and passiverange of motion (ROM) than do pa-tients with pyarthrosis.

Patients with gouty tenosynovitismay have a clinical presentation sim-ilar to that of PFT and may exhibitany of the four Kanavel signs, al-though patients with gouty tenosyn-ovitis typically exhibit fewer dra-matic signs than do patients withPFT.29,30 Diagnosis of gout or

pseudogout can be confirmed via as-piration of the involved joint or ten-don sheath, followed by crystal anal-ysis. The presence of tophaceousdeposits provides strong proof ofgout. Gout and infection may beconcurrent; therefore, the decision toproceed with antibiotic or surgicalmanagement should be based pri-marily on clinical suspicion for infec-tion as well as initial Gram stain andculture results.

Other Hand InfectionsParonychia, felons, cellulitis, anddeep space infections of the hand canbe confused with infection of theflexor tendon sheath, especially if theinfection is severe. Patients withparonychia experience the most dra-matic pain, swelling, and erythemaadjacent to the nail fold, whereas pa-tients with felons experience themost severe pain at the distal pulp ofthe finger (Figure 6). Palpable fluctu-ance or tense localized swelling can

Clinical photograph of a fingerdemonstrating herpetic whitlow.Note the coalescence of the fluid-filled vesicles. (Reproduced withpermission from Stern PJ: Selectedacute infections. Instr Course Lect1990;39:539-546.)

Figure 5

Clinical photograph of the left handdemonstrating a felon of the indexfinger. Note that the tense swellingof the pulp does not extend moreproximally along the tendon sheath.(Reproduced with permission fromStern PJ: Selected acute infections.Instr Course Lect 1990;39:539-546.)

Figure 6


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often be appreciated with both ofthese clinical entities. The patientwith cellulitis can be more easily as-sessed for PFT following elevation ofthe affected hand and administrationof antibiotics to decrease the initialswelling associated with cellulitis.Deep infections of the hand often re-sult in more diffuse swelling thanthat associated with PFT. Given theclose proximity of the spaces in thehand and the communication be-tween them, an infection in one area,especially when severe and pyogenic,may spread to adjacent spaces.Through this mechanism, PFT maybe associated with other hand infec-tions, including septic arthritis,paronychia, felon, and deep space in-fection.

Nonsurgical Management

Management of PFT has evolved toinclude prompt administration of IVantibiotics, and several surgicalmethods have been developed tothoroughly decompress and irrigatethe sheath. Nonsurgical treatmentmay be appropriate for patients withPFT who present early, typicallywithin 48 hours following penetrat-ing trauma to the hand. In a smallcase series, Neviaser and Gunther28

reported successful nonsurgical man-agement of PFT with IV antibiotics,splinting, and elevation in four pa-tients. Patients with early PFT mayhave less dramatic positive Kanavelsigns than those who present later.

During nonsurgical treatment, theaffected hand should be examinedregularly. If treatment is successful,improvement of clinical symptomsshould be seen within 48 hours.28 Ifno improvement or worsening ofsymptoms are seen within 12 to 24hours after initiating nonsurgicaltreatment, the patient should un-dergo surgical irrigation and dé-bridement.

Regardless whether surgical inter-vention is needed, IV antibiotics playa key role in treatment. Consultationwith an infectious disease specialistcan yield valuable information re-garding local antibiotic resistancepatterns, antibiotic choices, and du-ration of treatment. We do not rou-tinely consult an infectious diseasespecialist for management of uncom-plicated cases of PFT in an otherwisehealthy patient. However, consulta-tion can be helpful in the setting ofantibiotic-resistant organisms or im-munocompromised hosts.

Prior to obtaining culture results,antibiotic selection should includepresumptive coverage against com-mon Gram-positive organisms, in-cluding Staphylococcus (especiallyMRSA) and Streptococcus species.19

Presumptive antibiotics should alsocover Gram-negative rods and anaer-obes (including Clostridium species),especially in immunocompromisedpatients.19 These patients may re-quire additional antibiotics for pre-sumptive coverage of other bacteria.Given the prevalence of MRSA inour patient population, presumptiveantibiotic coverage in otherwisehealthy patients includes 1 g of van-comycin administered intravenouslyevery 12 hours and 3.375 g ofpiperacillin/tazobactam administeredintravenously every 6 hours to coverpossible Gram-negative rods inmixed-flora infections. In immuno-compromised hosts or in patientswith particularly severe PFT withsubcutaneous purulence, presump-tive treatment with antibiotics tocover both Gram-positive and Gram-negative bacteria is especially impor-tant because of the high incidence ofmixed-flora infections in this popula-tion. Once the results of the culturesare available, antibiotic regimensshould be tailored to cover the etio-logic organisms identified.

Duration of antibiotic treatmentdepends on the patient’s clinical re-

sponse. IV antibiotics are continueduntil the transition can be made tospecific oral medication based onculture results. In recalcitrant casesof PFT, IV antibiotics are continuedand, occasionally, repeat irrigationand débridement is necessary. At thetime of discharge, we prescribe anadditional 10-day course of oral an-tibiotics (eg, cephalexin 500 mg ordicloxacillin 500 mg every 6 hoursfor oxacillin-sensitive S aureus, clin-damycin 600 mg every 6 hours andtrimethoprim/sulfamethoxazole DS160/800 mg twice daily for MRSA).For culture-negative infection, broad-spectrum IV antibiotics can be discon-tinued with transition to multiplebroad-spectrum oral antibiotics (espe-cially those that cover MRSA). Dis-charge is based on improvement ofsymptoms on clinical examination.

Surgical Management

Open Irrigation andDébridementOpen irrigation and débridementprocedures were originally describedfor surgical management of PFT.5

Both midaxial and volar zigzag inci-sions can be used to expose and openthe entire sheath for complete drain-age and irrigation5,31 (Figure 7).Some believe that volar zigzag inci-sions should be avoided, given thepotential risk of wound breakdownover the flexor sheath and tendon.32

Open irrigation and débridement re-mains the treatment of choice for themost advanced cases of PFT and incases of atypical or chronic tenosyn-ovial infections in which completetenosynovectomy may be necessaryfor eradication of infection.1,17,28,31

We prefer to close all wounds withminimal tension on the skin, and weleave space between each stitch to al-low for continued drainage and toencourage a tension-free healing en-vironment for the tissue.



Closed Tendon SheathIrrigationAlthough initially described byDickson-Wright,33 Neviaser1 wroteextensively on closed tendon sheathirrigation for management of PFT. Aproximal zigzag incision is madeover the metacarpal neck. The ten-don sheath is incised transversely atthe proximal edge of the A1 pulley,and synovial fluid is collected forculture. Under direct visualization, a16- or 18-gauge angiocatheter is thenthreaded 1.5 to 2 cm into the flexortendon sheath. Next, a distal midax-ial incision is made dorsal to the neu-rovascular bundle at the level of thedistal interphalangeal joint on the ul-nar aspect of the finger or the radialaspect of the thumb. The distal edgeof the sheath is exposed and resecteddistal to the distal-most pulley. APenrose drain is threaded into thetendon sheath beneath the A4 pulleyto allow for drainage of irrigant (Fig-ure 8). The sheath is flushed gentlyin the operating room, and intermit-tent bedside irrigation can be contin-ued postoperatively, if desired. ForPFT infections of the thumb, theproximal catheter is placed into theFPL sheath just distal to the carpalcanal. For the small finger, if the ul-nar bursa is involved, a second cath-eter is placed distal to proximal fromthe A1 pulley, with another Penrosedrain placed at the wrist. Neviaser1

reported excellent results with thistechnique, including full active ROMat 1 week postoperatively in 18 of 20patients.

Gutowski et al31 retrospectivelycompared closed-catheter irrigationwith open irrigation and débride-ment for management of PFT. Theauthors found no significant differ-ences between the groups in terms ofearly postoperative outcomes, in-cluding resolution of infection, needfor additional surgery, and length ofhospital stay. They found a trend to-

ward more surgical complications inthe open drainage group, but thistrend was not statistically significant.Although no long-term results werereported due to poor follow-up, thestudy supports the possible superior-ity of closed irrigation over open irri-gation and débridement for manage-ment of PFT.

The best irrigant for closed irrigationis debated. Many believe that antibioticirrigants are no better at eradicating in-fection than is lavage with normal sa-line alone.1,2,31 Others argue that lo-cal antibiotics may elicit a localsynovitis reaction and that effective

selection of antibiotics is difficult inthe absence of culture data.1,2,31,32 Ingeneral, good results have been re-ported with the use of local antibiot-ics and bactericidal irrigants.14,33-35

However, other irrigants, such as hy-drogen peroxide, may cause celldeath in native tissue and should beavoided.1,31 Although more researchis required to define concentrationstoxic to local tissues, locally adminis-tered antibiotics may provide localcontrol of infection without risk ofsystemic toxicity.

Illustration demonstratingplacement of a midaxial incision foropen drainage of pyogenic flexortenosynovitis. This approach maybe combined with a transverseincision at the level of the distalpalmar crease to gain proximalaccess to the tendon sheath fordrainage or to obtain a culture.(Redrawn with permission fromStevanovic MV, Sharpe F: Acuteinfections, in Wolfe SW, HotchkissRN, Pedersen WC, Kozin SH:Green’s Operative Hand Surgery,ed 6. Philadelphia, PA, ChurchillLivingstone, 2011, vol 1, pp 41-84.)

Figure 7

Illustration demonstratingNeviaser’s technique for closedtendon sheath irrigation. Thetechnique consists of a proximalzigzag incision for exposure of thetendon sheath, introduction ofirrigant into the sheath through acatheter, and a distalcounterincision into which aPenrose drain is placed to allowirrigant drainage. (Redrawn withpermission from Stevanovic MV,Sharpe F: Acute infections, inWolfe SW, Hotchkiss RN, PedersenWC, Kozin SH: Green’s OperativeHand Surgery, ed 6. Philadelphia,PA, Churchill Livingstone, 2011, vol1, pp 41-84.)

Figure 8


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Continuous ClosedIrrigationUse of a continuous closed irrigationsystem is a popular option for man-agement of PFT. Advantages of thesesystems include the patient’s abilityto participate in hand therapy withthe system in place and avoidance ofpain caused by high pressures associ-ated with intermittent closed irriga-tion.2,4,14 Single catheter and nestedcatheter irrigation systems with cath-eters threaded through the tendonsheath have been described.2,4,16,36 Innested catheter systems, an infantfeeding tube (No. 4 French) serves asan inflow catheter and is threaded ina distal-to-proximal direction within

a slightly larger pediatric feedingtube (No. 8 French) threaded proxi-mal to distal; the larger tube servesas an outflow catheter for irrigant2,16

(Figure 9). This system helps to mini-mize soft-tissue blockage of the cath-eters and allows them to telescopewithin each other during ROM exer-cises. Duration of treatment with anested catheter system ranges from 2days to 3 weeks and is reported toproduce good results, with uniformeradication of infection.2,16

Recently, Gaston and Greenberg36

described another irrigation systemin which there is a continuous infu-sion of a local anesthetic (eg, bupiva-caine) via an external pump. A cath-eter is passed distal to proximalthrough the sheath to provide con-tinuous anesthetic irrigation. Thissystem reportedly provides less pain-ful continuous irrigation and allowsfor more active participation in handtherapy, with shorter periods of con-tinuous irrigation (2 days) and atrend toward shorter hospital stays(average, 2.8 days).36 The authors

emphasize correct placement of thecatheter lateral to the flexor tendonsto permit easier passage of the cathe-ter, avoid entrapment at the Camperchiasm, and minimize trauma to thesheath, tendons, and vinculae (Figure10).

Postoperative Irrigation

Duration of postoperative irrigationfor management of flexor tendonsheath infection varies in the litera-ture. In two series in which thoroughintraoperative tendon sheath irriga-tion was performed in patients withhand infections,2,36 the duration ofindwelling catheter treatment wasshorter than that of other trials,16

suggesting that thorough intraopera-tive irrigation may be the most im-portant surgical step for manage-ment of these infections. Althoughno study has examined the effects ofleaving an indwelling catheter in thetendon sheath, the practice itself mayresult in complications. Cathetersmay increase digital stiffness by de-creasing the patient’s ability to par-ticipate in therapy or may cause aforeign body reaction if left in placetoo long. The surgeon must weighthese risks with the potential benefitsof postoperative catheter irrigation.Lille et al3 retrospectively comparedthe results of intraoperative closedtendon sheath irrigation alone withthose of intraoperative and postoper-ative closed tendon sheath irrigation.They found no significant differencesin terms of mean length of hospitalstay, follow-up complication rates,or postoperative ROM, suggestingthat postoperative intermittent orcontinuous irrigation is not required.

Future Directions

In a recent animal study, Draegeret al37 reported promising resultswith local injection of antibiotics

Illustration demonstrating thenested catheter method ofcontinuous irrigation described byHarris and Nanchahal2 and Nemotoet al.16 An infant feeding tube ispassed into the sheath in a distal-to-proximal direction and isthreaded into a pediatric feedingtube passed into the sheath proxi-mal to distal. (Redrawn with per-mission from Harris PA, NanchahalJ: Closed continuous irrigation inthe treatment of hand infections. JHand Surg Br 1999;24[3]:328-333.)

Figure 9

Cross-sectional illustration of a digitdemonstrating placement of theirrigation catheter (arrow) lateral tothe flexor tendons to avoidentrapment in the Camper chiasm.(Adapted with permission fromGaston RG, Greenberg JA: Use ofcontinuous marcaine irrigation inthe management of suppurativeflexor tenosynovitis. Tech Hand UpExtrem Surg 2009;13[4]:182-186.)

Figure 10



into the tendon sheath and the addi-tion of locally administered cortico-steroids to the PFT treatment regi-men. However, clinical studies arerequired before these modalities canbe implemented in clinical practice.Just as corticosteroids have beenshown to decrease morbidity in otherclosed-space infections (eg, septic ar-thritis,38 septic nephritis39) by damp-ening the host’s inflammatory re-sponse, Draeger et al37 found thatcorticosteroids also decreased digitstiffness associated with PFT. This iscompelling preclinical evidence forthe efficacy of corticosteroids as anadjunctive treatment for PFT.

Complications

The primary complication associatedwith PFT is stiffness secondary toflexor tendon adhesions, joint capsu-lar thickening, or destruction of thesheath and pulley system as a resultof infection or iatrogenic injury.32

Other complications include tendonrupture, spread of infection to sur-rounding structures, or loss of theskin over infected tissue, which maynecessitate flap coverage.32 Most PFTinfections can be managed withoutamputation; however, patients withosteomyelitis, soft-tissue loss, orstiffness may require amputation ofthe affected digit.

In several series, 10% to 25% ofpatients with PFT failed to obtainfull ROM despite treatment.1-3,14,36

Full active ROM exercises should beinitiated immediately postoperativelyto decrease stiffness. In patients withhand stiffness despite physical ther-apy, flexor tenolysis can be per-formed to restore some active ROMonly after the tissue bed has reachedequilibrium (ie, local inflammation isabsent) and passive motion exceedsactive motion.15

Despite aggressive management ofPFT, two studies reported amputa-

tion incidence of 17%17 and 29%.18

Maloon et al18 found that amputa-tion was often necessary in patientswith diabetes and of delayed presen-tation. Pang et al17 identified five riskfactors associated with an increasedrisk of amputation in patients withPFT, including (1) age >43 years, (2)diabetes mellitus, peripheral vasculardisease, or renal failure, (3) presenceof subcutaneous purulence, (4) signsof digital ischemia at presentation,and (5) the presence of multiplecausative organisms. The authorsproposed a classification systembased on increasingly severe clinicalpresentation: Kanavel cardinal signs;subcutaneous purulence; and digitalischemia, which was found to corre-late with worse outcomes in patientswith PFT. In 21 patients with Kana-vel signs alone, no amputations wererequired, and the average recovery oftotal active motion in the digits was80%.17 In 37 patients with Kanavelsigns and subcutaneous purulencewithout digital ischemia, the ampu-tation rate was 8%, and the returnof total active motion in the remain-ing digits was 72%. The amputationrate in 17 patients with all three ofthe classification criteria was 59%,and the return of total active motionin the remaining digits was 49%.

Summary

Flexor tendon sheath infections ofthe hand continue to present clinicalchallenges despite advances in antibi-otic therapy and surgical manage-ment. Prompt diagnosis and manage-ment is paramount to avoid digit andtendon ischemia from increased pres-sure in the sheath. Kanavel cardinalsigns are useful for diagnosis, andtenderness along the flexor tendonsheath (often extending into thepalm) and pain with passive exten-sion of the digit are signs that are es-pecially helpful in differentiating

PFT from other conditions. Presump-tive antibiotic therapy should bebroad and include coverage of S au-reus, Streptococcus species, andGram-negative organisms until cul-ture results are available to allow tai-loring of antibiotic therapy to thecausative organism.

Management of PFT should in-clude thorough irrigation of the ten-don sheath via closed methods inmost cases or open methods in ad-vanced cases with digital ischemia.Even with prompt treatment, pa-tients with minimal comorbiditiescan develop permanent finger stiff-ness. Hand therapy is often requiredto maximize digital motion. Pooroutcomes, including amputation ofthe affected digit, may occur despiteaggressive débridement and antibi-otic therapy in patients with comor-bidities (eg, diabetes mellitus) andthose who present late and have digi-tal ischemia or subcutaneous puru-lence. Prospective trials are needed todetermine the efficacy of adjunctivecorticosteroids or local antibiotic in-jection.

References

Evidence-based Medicine: Levels ofevidence are described in the table ofcontents. In this article, reference 38 isa level I study. Reference 17 is a level IIstudy. References 3, 19, and 31 arelevel III studies. References 1, 2, 4, 13,14, 16, 18, 21, 23-25, 27, 29, 30, 34,and 36 are level IV studies. References33 and 35 are level V expert opinion.

References printed in bold type arethose published within the past 5 years.

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June 2012, Vol 20, No 6 381

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