Citation, DOI, disclosures and article data
Citation:
Rasuli B, Knipe H, Carroll D, et al. Pyogenic flexor tenosynovitis. Reference article, Radiopaedia.org (Accessed on 29 Mar 2024) https://radiopaedia.org/articles/81342?iframe=true
Pyogenic flexor tenosynovitis is a serious infection of the flexor tendon sheath of a finger that can lead to devastating consequences if delayed 1,2. With the early diagnosis and treatment of pyogenic flexor tenosynovitis, the serious sequelae of infection are markedly decreased. In a large series study, pyogenic flexor tenosynovitis compromised ~10% of all hand infections 3.
Four signs described by Kanavel 5,6 (commonly known as “Kanavel’s signs”) are frequently used as primary clinical items for diagnosis because advanced imaging and laboratory data are often non-specific 4 :
- exquisite tenderness throughout the sheath is limited to the sheath
- flexion of the finger
- excruciating pain on extending the finger, mostly at the proximal end, even with passive extension
- fusiform swelling, sometimes termed sausage finger or sausage digit by clinicians
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Ultrasound
Sonographic findings potentially supportive of the diagnosis include 9,10:
- fluid collection within synovial sheath: may range from anechoic to echogenic and heterogenous
- increased tendon diameter
- disruption of organized fibrillar architecture
Treatment and prognosis
Traditionally urgent surgery has been viewed as the standard of care however in some cases conservative management comprised of IV antibiotics, elevation and immobilization 7 have been trialled with positive results. It is important to note that delayed proper treatment can lead to necrosis and adhesions of the tendon and subsequent immobility, deformity, and even limb amputation 1,2.
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1. Stern P, Staneck J, McDonough J, Neale H, Tyler G. Established Hand Infections: A Controlled, Prospective Study. J Hand Surg Am. 1983;8(5):553-9. doi:10.1016/s0363-5023(83)80124-5
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2. Stevanovic MV, Sharpe F. Acute infections. In Wolfe SW, Pederson WC, Hotchkiss RN, Kozin SH, eds. Green’s Operative Hand Surgery. 6th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2011:41–84.
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3. Glass K. Factors Related to the Resolution of Treated Hand Infections. J Hand Surg Am. 1982;7(4):388-94. doi:10.1016/s0363-5023(82)80150-0
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4. Draeger RW, Bynum DK Jr. Flexor tendon sheath infections of the hand. J Am Acad Orthop Surg. 2012;20:373–382.
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5. Kanavel AB. The symptoms, signs, and diagnosis of tenosynovitis and fascial-space abscesses. In Infections of the Hand. 1st ed. Philadelphia, PA: Lea & Febiger; 1912:201–226.
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6. Kanavel AB. Infections of the Hand: A Guide to the Surgical Treatment of Acute and Chronic Suppurative Processes in the Fingers, Hand and Forearm. 7th ed. Philadelphia, PA: Lea & Febiger; 1939.
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7. Kennedy C, Huang J, Hanel D. In Brief: Kanavel's Signs and Pyogenic Flexor Tenosynovitis. Clin Orthop Relat Res. 2016;474(1):280-4. doi:10.1007/s11999-015-4367-x - Pubmed
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8. DiPasquale A, Krauss E, Simpson A, Mckee D, Lalonde D. Cases of Early Infectious Flexor Tenosynovitis Treated Non-Surgically With Antibiotics, Immobilization, and Elevation. Plast Surg (Oakv). 2017;25(4):272-4. doi:10.1177/2292550317731765 - Pubmed
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9. Hubbard D, Joing S, Smith S. Pyogenic Flexor Tenosynovitis by Point-Of-Care Ultrasound in the Emergency Department. Clin Pract Cases Emerg Med. 2018;2(3):235-40. doi:10.5811/cpcem.2018.3.37415 - Pubmed
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10. Amini R, Camacho L, Acuña J, Situ-La Casse E, Adhikari S. Point of Care Ultrasound in Pyogenic Tenosynovitis: A Case Report. Bull Emerg Trauma. 2020;8(1):41-6. doi:10.29252/beat-080107 - Pubmed
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