4: Drainage of Purulent Flexor Tenosynovitis

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Procedure 4 Drainage of Purulent Flexor Tenosynovitis

Brent M. Egeland, Sandeep J. Sebastin, Kevin C. Chung

Indications

image Clinical diagnosis of acute suppurative tenosynovitis or an infection within the closed space of the fibrous flexor sheath requires early, aggressive treatment.

• Patients with symptoms lasting longer than 24 to 48 hours
• Failure of improvement of symptoms with intravenous antibiotics in patients with symptoms for less than 24 hours
• Diabetic or immunocompromised patient

image Drainage is performed to prevent secondary sequelae of tendon sheath inflammation: stiffness, scarring, or tendon rupture.

Examination/Imaging

Clinical Examination

image Purulent flexor tenosynovitis is a clinical diagnosis.

image Kanavel signs (Fig. 4-1A and B) are as follows:

• Painful finger held in a slightly flexed position
• Fusiform swelling of the finger, sometimes swelling of the entire hand
• Significant pain with passive extension (or active flexion of the finger)
• Tenderness to palpation along the volar surface of the finger—at the flexor sheath

image Finger erythema is variable.

image Evaluate for possible prior penetrating trauma to the palmar aspect of the digit, which may have seeded bacteria into the tendon sheath.

image Tenosynovitis of the thumb and small finger may be less impressive owing to continuity of the fibrous flexor sheath with larger radial and ulnar bursa that allow spontaneous decompression (Fig. 4-2).

image Infection of the thumb may spread to the small finger and vice versa.

image Examine for signs of gout or other intra-articular processes, which are treated medically.

image Examine for symptoms not confined to one joint. (Gout is typically monoarticular.)

image Without a prior penetrating wound, consider disseminated gonococcal infection or hematogenous spread of bacteria from other sources.

image

FIGURE 4-1

image

FIGURE 4-2

Imaging

image Standard anteroposterior and lateral radiographs of the hand and affected digit should be obtained to rule out a radiopaque foreign body, osteomyelitis, pyoarthrosis, or occult trauma.

Surgical Anatomy

image The fibrous flexor sheath (flexor zone 2) is an enclosed space extending from the metacarpal neck to just proximal to the distal interphalangeal (DIP) joint (see Fig. 4-2).

image The small finger flexor sheath is in continuity with the ulnar bursa, extending to the proximal transverse carpal ligament.

image The thumb flexor sheath is in continuity with the radial bursa, extending to the proximal aspect of the transverse carpal ligament.

image Radial and ulnar bursae may communicate to form a horseshoe abscess via the space of Parona in the volar forearm, between the pronator quadratus and the flexor digitorum profundus.

image The anatomy of the annular pulley system is critical to identifying proximal and distal exposures at A1 and A4, respectively.

Positioning

image The procedure is performed under tourniquet control.

image Use of an Esmarch bandage for exsanguination is risky because it can spread the infection proximally.

image The operation is done under regional or general anesthesia.

Exposures

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