Pyogenic flexor tenosynovitis

Last revised by Henry Knipe on 1 Feb 2022

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

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

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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