- See:
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Hand Infections - Menu
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Kanavel's signs
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Thumb Flexor Sheath Infections
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Workup and Treatment:
- Relevant Anatomy:
- index, long, & ring tendon sheaths of most hands extend from terminal phalanges to a point just distal to
superficial palmar arch;
- occassionally they may extend to the wrist;
- proximal ends of flexor sheaths overlie distal ends of
thenar and
midpalmar spaces;
- thumb tendon sheath communicates w/ the
radial bursa;
- little finger tendon sheath (sometimes
third & fourth sheaths) will extend to and communicate with
ulnar bursae;
-
radial &
ulnar bursae communicate proximal to the carpal tunnel in 50-80% of patients;
- accounts for horse shoe tenosynovitis;
- horse shoe abscess are drained by a combination of incisions into little finger (ulnar bursae and radial bursa incisions);
-
lumbrical muscle sheaths
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mid palmar space
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paron's space
- Exam:
-
Kanavel's signs
- goal is to distinguish infectious tenosynovitis from superficial or localized abscess (see
felon);
- pain w/ finger extension may be the earliest sign present;
- look for signs of direct penetration, esp at flexor creases;
- in cases, where signs of direct innoculation are not present, consider
neiserria tenosynovitis;
- Laboratory Considerations:
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bacteriology of hand infections:
- gram stain:
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gram negative bacilli:
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gram negative cocci:
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gram positive bacilli:
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gram positive bacilli
- Non Operative Treatment:
- infectious tenosynovitis is a true orthopaedic emergency and in most cases immediate drainage in the OR is required;
- if
infectious tenosynovitis is diagnosed within 24 to 48 hrs of onset of symptoms,
it may also be treated w/
antibiotics, along w/ splinting and hand elevation;
- note, however, that operative treatment is usually required;
-
antibiotic treatment based on organism:
- Surgical Treatment:
- if there is no dramatic improvment after 24 hrs of antibiotics or if injury is more than 48 hours old, surgical drainage is indicated;
- if tendon sheath infection is seen late or is not treated properly early, skin loss, tendon necrosis, & subsequent osteomyelitis can result;
-
closed suction drainage:
- is a commonly used form of treatment, but is high maintenance, and is uncomfortable for the patient;
- many surgeons prefer immediate open draninage;
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open drainage:
- if infection has gotten out of control, closed irrigation is not be possible;
- in this case open drainage may be required;
-
posterolateral finger incision has the advantage of being able to loosely cover the flexor
tendons postop (as opposed to zig-zag incisions which tend to gap open and expose the tendons to dissication);
