M

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MM

• 9/11/07
• Resident-Uliyargoli.A

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• 57 AA M
• No DM
• Paronychia of left index finger- drained 2 days
  earlier
• ER- Diffuse swelling and pain of L index finger
  and did submit to low grade fevers
• No h/o any penetrating injuries or trauma

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• O/E- Diffuse swelling of the left index finger
• Finger in partially flexed position
• Kanavels sign- positive (pain on passive flexion)
• Sensation intact
• Imp- Flexor tenosynovitis of the index finger

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• WBC-15
• Other labs N
• Underwent I D under GA
• Longitudinal lateral incisions placed along
  lateral edges of the mid and proximal phalanx
• Copious amts of pus drained,
• Penrose drains placed transversely, traversing
  the space, superficial to tendons, in the 2
  spaces
• Placed on Vanc and zosyn

5

• Pain and swelling decreased over the finger,
  increased movements
• WBC ?
• Over the next 2-3 days blackening of the tip of
  the finger and skin overlying the mid and
  proximal phalanx appeared white and devitalised
• Cultures- B-hemolytic streptococci
• Antbx- Changed to Augmentin

6

• With persistent drainage and areas of skin
  appearing necrotic pt referred to hand
  specialist at Franklin Square.
• F/U- the tip of the finger was amputated and long
  longitudinal incisions made to flay open the
  synovial sheath and provide adequate drainage

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Complication

• Inadequate drainage with persistent infection
• Loss of finger tip and likely loss of function

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Infectious Tenosynovitis

• Inflammation of the tendon and tendon sheath
• Hand anatomy- Flexor tendons in the fingers run
  in tight fibro-osseous tunnels lined by double
  layered synovium. The index, long, ring tendon
  sheaths of most hands extend from terminal
  phalanges to a point just distal to mid palm.
• The index finger sheath lies over the deep thenar
  space and infections may extend into this space
  presenting with fullness of the palm

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• Thumb tendon sheath communicates w/ the radial
  bursa
• Little finger tendon sheath will extend to and
  communicate with Ulnar bursa
• Radial and Ulnar bursa communicate proximal to
  the carpal tunnel in 50-80 of patients
  presenting as a horseshoe abscess

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Bacteriology

• Most common- Staph and strep, Commonly sensitive
  to Unasyn, augmentin
• N.Gonorrhoea- non traumatic
• E.Corrodens- human bites
• Rare- V.vulnificus, Mycobacteria, Herpes, LGV,
  Fungal

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• Kanavels sign- Pain on finger extension is an
  early sign
• Look for signs of minor trauma, direct
  penetration esp. at flexor creases
• Signs of trauma not present, consider neiserria

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True emergency

• In most cases immediate drainage in the OR is
  required
• If infectious teno-synovitis is diagnosed within
  24 to 48 hrs of onset of symptoms, it may be
  treated w/antibiotics, along w/ splinting and
  hand elevation
• Operative treatment is usually required

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• Postero-lateral finger incision preferred- raised
  flaps can loosely provide cover to the flexor
  tendons postop (zig-zag incisions tend to gape
  open and expose the tendons to dessication)
• Tendon sheath infection if seen late or is not
  treated properly early, skin loss, tendon
  necrosis, subsequent osteomyelitis can result