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Rao V, Snapp WK, Crozier JW, Bhatt RA, Schmidt ST, Kalliainen LK. Limited Flexor Sheath Incision and Drainage in the Emergency Department in the Management of Early Pyogenic Flexor Tenosynovitis. Hand (N Y) 2023; 18:320-327. [PMID: 33880957 PMCID: PMC10035092 DOI: 10.1177/1558944721999729] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pyogenic flexor tenosynovitis (PFT) has been considered a surgical emergency. Varying operative approaches have been described, but there are limited data on the method, safety, and efficacy of nonoperative or bedside management. We present a case series where patients with early flexor tenosynovitis are managed using a limited flexor sheath incision and drainage (I&D) in the emergency department (ED) to both confirm purulence within the flexor sheath and as definitive treatment. METHODS A retrospective study of all patients clinically diagnosed in the ED with flexor tenosynovitis at our institution from 2012 to 2019 was performed. Patients with frank purulence on examination were taken emergently to the operating room (OR). Patients with equivocal findings underwent limited flexor sheath I&D in the ED. Safety and efficacy were studied for patients with early flexor tenosynovitis managed with this treatment approach. RESULTS Thirty-four patients met the inclusion criteria. Ten patients underwent direct OR I&D, and 24 patients underwent ED I&D. In the ED I&D group, 96% (24 of 25) of patients did not have frank purulence in the flexor sheath and were managed with bedside drainage alone. There were no procedural complications and no need for repeat operative intervention. Time to intervention (3.1 hours vs 8.4 hours) was significantly shorter for the ED I&D group compared with the OR I&D group. Within the ED I&D group, 86% of patients exhibited good/excellent functional scores. CONCLUSIONS Limited flexor sheath I&D in the ED provides a potential safe and effective way to manage patients with early flexor tenosynovitis.
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Affiliation(s)
- Vinay Rao
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - William K. Snapp
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Joseph W. Crozier
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Reena A. Bhatt
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Scott T. Schmidt
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
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Neill E, Anaya N, Graglia S. Point-of-care ultrasound for diagnosis of purulent flexor tenosynovitis. Emerg Med J 2021; 39:716-718. [PMID: 34140320 DOI: 10.1136/emermed-2020-211113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Emily Neill
- Emergency Medicine, University of California San Francisco, San Francisco, California, USA .,Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Nancy Anaya
- Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Sally Graglia
- Emergency Medicine, University of California San Francisco, San Francisco, California, USA
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Risk of septic spread during surgical management of digital flexor tendon sheath phlegmon: Exsanguination by mechanical compression versus simple elevation. HAND SURGERY & REHABILITATION 2021; 40:650-654. [PMID: 34029765 DOI: 10.1016/j.hansur.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/03/2021] [Accepted: 05/14/2021] [Indexed: 11/23/2022]
Abstract
This study aimed to demonstrate that there was no risk of extension of infection in performing mechanical exsanguination before inflating the tourniquet for surgical treatment of digital flexor tendon sheath phlegmon. The series comprised 96 patients, with a mean age of 47 years (range, 18-87 years) and 37 women. Group I included 47 patients in whom exsanguination was performed with a Velpeau band before inflating the pneumatic tourniquet at the root of the limb. In Group II, which included 49 patients, the tourniquet was inflated after simple elevation of the limb. Six patients underwent revision surgery for recurrence or osteoarticular complications: 4 (8.5%) in Group I and 2 (4.1%) in Group II, the difference between two groups being non-significant (p = 0.6378). In conclusion, mechanical exsanguination before inflating the tourniquet did not incur risk of complications in surgical management of digital flexor tendon sheath phlegmon.
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Infections of Deep Hand and Wrist Compartments. Microorganisms 2020; 8:microorganisms8060838. [PMID: 32503146 PMCID: PMC7356554 DOI: 10.3390/microorganisms8060838] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/28/2020] [Accepted: 06/01/2020] [Indexed: 12/20/2022] Open
Abstract
The human hand is the most exposed part of the body to highest risk for injuries, loss of the skin integrity, and to the inoculation of bacteria, most commonly Staphylococcus aureus, Streptococcus β-haemolytic, and gram-negative. In case of an infection, the mobile anatomical structures and the synovial membranes in close proximity to each other may spread the pus towards deep spaces and compartments. Mild early infections without an abscess formation may respond to antibiotics, but at more advanced stage, erythema, swelling, stiffness, and severe pain may ensue. Abscess formation will cause debilitating pain, fever, systemic symptoms, and even sepsis. Necrotizing infections may threaten not only the limb, but also patient’s life. Therefore, an initially “trivial” hand injury should never be neglected, as it might turn into a deep space infection, which must be treated immediately with drainage, wound debridement, and i.v. antibiotics. Delay in diagnosis and inadequate initial management might rapidly lead to abscess formation, destruction of the gliding surfaces and the normal anatomy, and irreparable functional deterioration.
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Boyer E, Igeta Y, Facca S, Xavier F, Liverneaux P, Prunières G. Surgical treatment of phlegmons of the digital flexor tendon sheaths at the early stage: Lavage by conventional open technique versus ultrasound-guided percutaneous technique. ANN CHIR PLAST ESTH 2019; 64:344-350. [DOI: 10.1016/j.anplas.2019.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 04/19/2019] [Indexed: 11/25/2022]
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Boyer E, Igeta Y, Jiang S, Arianni M, Goldammer F, Prunières G, Paun A, Vernet P, Liverneaux P. Designing a minimally-invasive, ultrasound-guided, percutaneous flexor tendon sheath lavage technique: a cadaver study. HAND SURGERY & REHABILITATION 2019; 38:87-90. [PMID: 30655220 DOI: 10.1016/j.hansur.2018.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 09/25/2018] [Accepted: 12/14/2018] [Indexed: 11/28/2022]
Abstract
The goal of this study was to develop a minimally-invasive, ultrasound-guided percutaneous flexor tendon sheath lavage technique on cadaver model. Two catheters were inserted using ultrasound guidance at the proximal and distal ends of the tendon sheath in 20 fingers from cadaveric forearms. Percutaneous injection of a saline solution colored with methylene blue resulted in anterograde lavage of the flexor tendon sheath. The technique was successful in 13 out of 20 cases. The proximal catheter was in the correct position in 17 cases and the distal catheter was correctly positioned in 15 cases. The flexor tendons were continuous in all cases and had puncture wounds in 9 cases. Based on our study, this minimally-invasive, ultrasound-guided percutaneous lavage of the flexor tendon sheath was effective in 65% of cases and safe in 100% of cases in the index, middle and ring fingers. If this percutaneous lavage fails, it is always possible to switch to a conventional open technique.
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Affiliation(s)
- E Boyer
- Department of Hand Surgery, SOS main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10 avenue Baumann, 67400 Illkirch, France
| | - Y Igeta
- Department of Hand Surgery, SOS main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10 avenue Baumann, 67400 Illkirch, France; Department of Orthopedic Surgery, Juntendo Nerima Hospital, 3-1-10, Takanedai, Nerima-ku, Tokyo, 177-8521, Japan
| | - S Jiang
- Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, 138 Yixueyuan Road, Shanghai, 200040, China; Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital, No.12 Wulumuqi Middle Road, 200040, Shanghai, Popular Republic of China
| | - M Arianni
- Hand Clinic, Ramsay Premier Bintaro Hospital, Jl. MH Thamrin no.1, Bintaro Jaya sector Tangerang Selatan, 15224, Banten, Indonesia
| | - F Goldammer
- Department of Hand Surgery, SOS main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10 avenue Baumann, 67400 Illkirch, France
| | - G Prunières
- Department of Hand Surgery, SOS main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10 avenue Baumann, 67400 Illkirch, France
| | - A Paun
- Department of Hand Surgery, SOS main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10 avenue Baumann, 67400 Illkirch, France
| | - P Vernet
- Department of Hand Surgery, SOS main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10 avenue Baumann, 67400 Illkirch, France
| | - P Liverneaux
- Department of Hand Surgery, SOS main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10 avenue Baumann, 67400 Illkirch, France.
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