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Marks A, Schraft E, Gottlieb M. Skin, Soft Tissue, and Musculoskeletal Ultrasound. Emerg Med Clin North Am 2024; 42:863-890. [PMID: 39326992 DOI: 10.1016/j.emc.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2024]
Abstract
Point-of-care ultrasound may be used to assist in the diagnosis of skin, soft tissue, and musculoskeletal concerns in the emergency department. Frequently, linear or curvilinear probes are used to perform these studies and ultrasound may be used to assist in common emergency department procedures related to these conditions.
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Affiliation(s)
- Amy Marks
- Department of Emergency Medicine, RUSH University Medical Center, Kellogg Suite 108, 1750 West Harrison Street, Chicago, IL 60612, USA.
| | - Evelyn Schraft
- Department of Emergency Medicine, RUSH University Medical Center, Kellogg Suite 108, 1750 West Harrison Street, Chicago, IL 60612, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, RUSH University Medical Center, Kellogg Suite 108, 1750 West Harrison Street, Chicago, IL 60612, USA
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Ruiz SG, Mentz JA, Smith DW. Hospital transfers for evaluation and treatment of hand infections: Are all transfers necessary? J Hand Microsurg 2024; 16:100083. [PMID: 39234361 PMCID: PMC11369712 DOI: 10.1016/j.jham.2024.100083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 04/16/2024] [Indexed: 09/06/2024] Open
Abstract
Background Hand infections represent a common hand condition in the emergency department and one that frequently requires a hand specialist. The purpose of our study is to analyze hospital transfers for hand infections with a primary outcome being potential clinically avoidable transfers and to identify areas for improvement in the care of hand infections. Methods Retrospective review of The Texas Healthcare Information Collection Database from 2015 to 2019. We analyzed all transfers for hand infections. Statistical analyses included: Transfer diagnosis, surgical interventions, length of stay (LOS), the day of the week that the transfer was initiated and whether or not the transfer or centralization was necessary or potentially avoidable. Results A total of 3489 patients were transferred from one hospital to another for the management of a hand infection. 1628 (46.6 %) underwent at least one surgical intervention and 1861 (53.3 %) were treated non-operatively. Patients undergoing operative interventions had a lower LOS compared to those non-operatively. Transfers admitted during the weekend had decreased average LOS relative to non-weekend transfers, but a 94.7 % increased odds of receiving a relevant surgical intervention during the hospital admission. Nearly all patients were transferred to urban region hospitals. Of total, 1194 (34.22 %) were considered potentially avoidable centralizations, which we defined as transfer that resulted in no surgical intervention and discharge to home within 72 h. Conclusions Although the reason for centralization was unknown, our analysis showed a high number of transfers that could have been potentially avoidable. We propose the development of specific guidelines, and perhaps the use of remote consultations for areas where hand specialist are not reliably available to help optimize the care of patient with hand infections.
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Affiliation(s)
- Samuel G. Ruiz
- Division of Plastic Surgery, Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - James A. Mentz
- Division of Plastic Surgery, Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Dean W. Smith
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, TX, USA
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Forder BH, Hennessy M, Turner B, Wormald J. Systematic review of treatment for pyogenic flexor tenosynovitis of the hand. J Plast Reconstr Aesthet Surg 2024; 96:23-32. [PMID: 39024677 DOI: 10.1016/j.bjps.2024.05.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 05/24/2024] [Indexed: 07/20/2024]
Abstract
AIMS Pyogenic flexor tenosynovitis (PFT) comprises 2.5-9.4% of all primary hand infections. Management is variable, including surgical intervention, systemic antibiotics, or both. However, there are no evidence-based treatment guidelines. We conducted a systematic review to determine the best evidence for existing interventions and a meta-analysis to summarise published data quantitatively. METHODS MEDLINE and Embase (OVID) databases were searched in January 2023 and March 2024. Screening and data extraction were performed in duplicate. The risk of bias was assessed using National Institute of Health study assessment tools. A protocol is available on PROSPERO (CRD42023411142), and the review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Data analysis was performed in RStudio. RESULTS 24 studies (n = 1108 patients) were included following screening of 2386 abstracts. All were retrospective (18 case series and six cohort studies). Surgical interventions were assessed in 22 studies, combined with specific antibiotic regimes in four studies. Two studies described non-operative management alone. The pooled mean hospital stay for those undergoing operative intervention was 8.3 days (SD 7.5, n = 552), compared to 4.76 days (SD 0.12, n = 58) for non-operative intervention. Two studies reported PROMs (DASH), reporting no difference when comparing operative and non-operative interventions. Most studies were of poor quality (20), with four being fair. CONCLUSIONS There is insufficient evidence in favour of one intervention regarding hospital stay or PROMs, including the superiority of operative management or non-operative approaches. Given the prevalence of PFT, management should be guided by robust data. Future experimental studies of surgical techniques and comparisons with non-operative management are warranted.
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Affiliation(s)
- Bea Harris Forder
- Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Megan Hennessy
- Medical Sciences Division, University of Oxford, Oxford, United Kingdom.
| | - Benedict Turner
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, United Kingdom
| | - Justin Wormald
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, United Kingdom
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R M, Kanchana K, Shankar A, J K. An Unusual Case of Tuberculous Tenosynovitis of the Hand. Cureus 2024; 16:e63081. [PMID: 39055437 PMCID: PMC11272143 DOI: 10.7759/cureus.63081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2024] [Indexed: 07/27/2024] Open
Abstract
Infectious tuberculous tenosynovitis (TS) is an unusual occurrence in the forearm, wrist, or hand. Here we report a case of tuberculous TS of the wrist in a 26-year-old male with no comorbidities. The patient presented with a nonhealing ulcer on the palmar aspect of the proximal part of the left little finger with restricted mobility. There were no other symptoms to confirm the existence of an active tuberculosis infection in this patient. This case report helps broaden our knowledge about the different presentations of tuberculous TS in a patient with no history of exposure to tuberculosis.
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Affiliation(s)
- Manimaran R
- Plastic Surgery, Sree Balaji Medical College & Hospital, Chennai, IND
| | - Koppolu Kanchana
- Plastic Surgery, Sree Balaji Medical College & Hospital, Chennai, IND
| | - Aiswerya Shankar
- General Surgery, Sree Balaji Medical College & Hospital, Chennai, IND
| | - Karthick J
- Plastic and Reconstructive Surgery, Sree Balaji Medical College & Hospital, Chennai, IND
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Fujihara Y, Sakai A, Niwa S, Ota H, Kumagai H. Delayed debridement affects prognosis in patients with purulent flexor tenosynovitis: a retrospective cohort and multivariate analyses. Arch Orthop Trauma Surg 2024; 144:2437-2441. [PMID: 38492063 DOI: 10.1007/s00402-024-05269-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/03/2024] [Indexed: 03/18/2024]
Abstract
INTRODUCTION Purulent flexor tenosynovitis (PFT) is a severe condition, and many patients report serious postoperative complications such as amputation, limited range of motion (ROM), or recurrence of symptoms. However, the ideal protocol for PFT treatment remains unknown owing to the limited number of studies. This retrospective cohort study aimed to identify prognostic factors for PFT treatment outcomes. MATERIALS AND METHODS Sixty-six patients (46 men and 20 women) with PFT who underwent surgical debridement at our hospital between September 2005 and January 2023 were included in this study. We conducted multivariate linear regression analysis with permanent deficit as the primary outcome. We defined the number of operations, laboratory data, interval from onset to debridement, previous conservative treatment, aetiology, Kanavel's signs, and medical history of diabetes mellitus as possible prognostic factors. We also defined the interval from onset to debridement as a secondary outcome and performed logistic regression analysis. RESULTS Overall, 25 (38%) patients had postoperative deficits. Longer interval from onset to surgery (odds ratio [OR]: 1.1, 95% confidence interval [CI]: 1.0-1.1) and polymicrobial infection (OR: 7.8, 95% CI: 1.56-38.8) were significant prognostic factors for unfavourable outcomes. Additional multivariate analysis showed that preoperative conservative treatment prolonged the interval to surgery (estimate, 16.4; standard error, 1.6; p < 0.05). CONCLUSIONS The results of this study suggest that indications for nonoperative treatment of PFT are limited and that earlier surgical debridement is recommended.
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Affiliation(s)
- Yuki Fujihara
- Department of Orthopaedic and Hand Surgery, Nagoya Ekisaikai Hospital, 4-66 Shonen-Cho, Nakagawa-Ku, Nagoya, 454-8502, Japan.
| | - Ai Sakai
- Department of Orthopaedic and Hand Surgery, Nagoya Ekisaikai Hospital, 4-66 Shonen-Cho, Nakagawa-Ku, Nagoya, 454-8502, Japan
| | - Satoshi Niwa
- Department of Orthopaedic and Hand Surgery, Nagoya Ekisaikai Hospital, 4-66 Shonen-Cho, Nakagawa-Ku, Nagoya, 454-8502, Japan
| | - Hideyuki Ota
- Department of Orthopaedic and Hand Surgery, Nagoya Ekisaikai Hospital, 4-66 Shonen-Cho, Nakagawa-Ku, Nagoya, 454-8502, Japan
| | - Hiroaki Kumagai
- Department of Orthopaedic and Hand Surgery, Nagoya Ekisaikai Hospital, 4-66 Shonen-Cho, Nakagawa-Ku, Nagoya, 454-8502, Japan
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Myers DM, Goubeaux C, Skura B, Warmoth PJ, Taylor BC. Contrast Enhanced Computed Tomography in the Diagnosis of Acute Pyogenic Flexor Tenosynovitis. Hand (N Y) 2023; 18:1323-1329. [PMID: 35611491 PMCID: PMC10617475 DOI: 10.1177/15589447221092058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The diagnosis of infectious flexor tenosynovitis (FTS) has historically been made based on physical exam using Kanavel's signs. The specificity of these findings has come into question. We looked to evaluate the use of contrast-enhanced computed tomography (CT) in increasing the successful diagnosis of FTS. METHODS Two adult cohorts were formed, one of patients with FTS confirmed in the operating room and the second of patients with ICD.10 identified finger cellulitis (FC), without concomitant FTS. Demographics, laboratory values, CT scans, and examination findings were evaluated. Axial CTs were evaluated in the coronal and sagittal planes and tendon sheath/tendon width were measured. The tendon sheath/tendon was recorded as a ratio in the coronal (CR) and sagittal (SR) planes. Continuous and dichotomous variables were analyzed and measures of sensitivity, specificity, and predictivity were calculated. Seventy patients were included, 35 in the FTS cohort and 35 with FC. RESULT A higher number of Kanavel signs were present in the FTS group (2.9 vs. 0.5, P < .05), with CR and SR both being significantly larger in the FTS group (P < .05). CR and SR cutoffs ≥ 1.3 provided high sensitivity, specificity, and positive predictive value (PPV) for FTS. Likelihood of FTS increased 5.9% and 5.5% for every 0.1 increase in CR and SR, respectively, with a 14% increase for every additional Kanavel sign. CONCLUSION In conclusion, CT ratios are useful in identifying FTS; and when used on their own or in combination with Kanavel's signs, CR and SR objectively improve the diagnosis of FTS.
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Affiliation(s)
| | | | - Brian Skura
- OhioHealth Grant Medical Center, Columbus, USA
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Latario L, Abeler J, Clegg S, Thurber L, Igiesuorobo O, Jones M. Antibiotics Versus Surgery in Treatment of Early Flexor Tenosynovitis. Hand (N Y) 2023; 18:804-810. [PMID: 35081807 PMCID: PMC10336807 DOI: 10.1177/15589447211043187] [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: 02/10/2023]
Abstract
BACKGROUND Treatment of pyogenic flexor tenosynovitis (FTS) historically involved surgical debridement supplemented with antibiotic therapy. No consensus exists on either: (1) the treatment algorithm for this infection; or (2) the clinical definition of "early" FTS. We performed a retrospective study to clarify indications for nonoperative management. METHODS We identified 40 patients with a diagnosis of FTS using Current Procedural Terminology and International Classification of Diseases, Tenth Revision, codes and a keyword search from an electronic medical record between 2011 and 2019. Patients underwent either surgical management (SG) (n = 20) or early antibiotics only (EAG) (n = 20). The surgical group was divided into patients with intraoperative purulence within the tendon sheath (PU) and those without purulence (NP). RESULTS The number of Kanavel signs and duration of days of symptoms were significantly greater in SG compared with EAG. Subgroup analysis of SG showed a greater number of days of symptoms in the NP group when compared with the PU group. No statistical significance was found with respect to age, smoking, or specific individual Kanavel signs between SG and EAG. CONCLUSIONS Both duration of symptoms and number of Kanavel signs should be considered in suspected early FTS. Patients with shorter duration of symptoms and fewer Kanavel signs were treated successfully with antibiotics alone. Operatively confirmed FTS presented more acutely with fewer days of symptoms and a higher number of Kanavel signs. Patients with subacute presentations may represent inflammatory conditions and hand infections other than FTS.
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Affiliation(s)
- Luke Latario
- Department of Orthopedic Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
| | - Jesse Abeler
- Department of Orthopedic Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
| | - Stephanie Clegg
- Department of Orthopedic Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
| | - Laura Thurber
- University of Massachusetts Medical School, Worcester, MA, USA
| | | | - Marci Jones
- Department of Orthopedic Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
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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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Inoculation of sonicate fluid into blood culture bottles improves microbial detection in patients with orthopedic bone and soft tissue infections of the upper and lower extremities. J Orthop Sci 2023; 28:476-483. [PMID: 34972615 DOI: 10.1016/j.jos.2021.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/16/2021] [Accepted: 11/12/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND The usefulness of sonicate fluid culture for biological tissues in orthopedic bone and soft tissue infections have not been reported. We assessed whether inoculating the sonicate fluid of bone and soft tissue into a blood culture bottle could increase the diagnostic accuracy for biofilm-related orthopedic infections. METHODS Twenty consecutive patients with infections (9 purulent arthritis, 4 osteomyelitis, 4 purulent tenosynovitis, 2 purulent bursitis, and 1 cellulitis) and 10 non-infected cases (6 carpal tunnel syndrome, 3 Dupuytren contracture, and 1 soft tissue tumor) between October 2018 and December 2020 were evaluated prospectively. We analyzed a total of 107 culture submissions (87 bone and tissue specimens and 20 controls); 42 intraoperative tissue specimens (32 infected samples and 10 non-infected samples) using the conventional method, 45 sonication samples (35 infected samples and 10 non-infected samples), and 20 control samples. Intraoperative infectious tissues were cultured using sonicate fluid culture in a blood culture bottle (SFC-CB). The applications of SFC-CB and the conventional culture method and the detection rate, sensitivity, and relationship between the sensitivity of the diagnostic methods and duration of administered preoperative antibiotics were assessed. RESULTS The causative microorganism was detected only by SFC-CB in five patients (25%). The sensitivity (85% vs. 60%; P = 0.077) and detection rate (80% vs. 60%; P = 0.065) were higher for SFC-CB than for the conventional culture method. The sensitivity of SFC-CB was significantly higher than that of the conventional culture method in cases in which preoperative antibiotics were administered for more than 1 week (77% vs. 39%; P = 0.047). CONCLUSIONS Using SFC-CB, the diagnostic accuracy for bone and soft tissue infection was significantly improved. As biofilms are readily formed in biological tissues, sonication may also be useful for diagnosis. SFC-CB was particularly useful for cases in which preoperative antibiotics were administered.
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Muacevic A, Adler JR, Bhandari L. A Comparison of Parenteral and Per-Oral Antibiotic Usage in Pyogenic Flexor Tenosynovitis: A Retrospective Study. Cureus 2022; 14:e32825. [PMID: 36694534 PMCID: PMC9864479 DOI: 10.7759/cureus.32825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Pyogenic flexor tenosynovitis (PFT) is a common hand infection that can cause significant morbidity. Although treatment involves surgical debridement and inpatient intravenous (IV) antibiotics, there is a paucity of literature guiding antibiotic use. This study aims to determine if the use of postoperative outpatient oral antibiotics leads to poor outcomes compared to IV antibiotics given in an institutional setting. Methods A retrospective review of 110 patients treated post-operatively with either outpatient oral or inpatient IV antibiotics at our institution from 2016-2019 was performed. All patients underwent surgical debridement. Primary outcomes analyzed included readmission, repeat surgery, and amputation. Clinical parameters including age, diabetes, smoking, duration of symptoms, involvement of surrounding structures (felon, dorsal abscess, osteomyelitis, septic arthritis), culture growth, Michon classification, and duration of antibiotics were analyzed as possible risk factors for poor outcome. The level of evidence of this study is Level 3 Retrospective Cohort Study. Results Seventy-five patients were treated with outpatient oral antibiotics and 35 patients were treated with inpatient IV antibiotics. The oral antibiotics group received antibiotics for 13.1 +/- 9.9 days compared to 18.1 +/-10.4 days in the IV antibiotic group. Patients in the oral antibiotic group had a significantly shorter length of hospitalization at 0.6 +/-1.8 days compared to 3.6 +/-1.8 days in the IV antibiotic group. The readmission rate for the oral antibiotic group was 10.7% compared to 5.7% in the IV antibiotic group. This difference was not statistically significant except in patients who had involvement in surrounding structures. There was no significant difference in repeat surgeries or amputations between the groups. Conclusions The use of outpatient oral antibiotics after surgical debridement for PFT does not significantly increase rates of readmission, repeat surgery, or amputation, except in cases with the involvement of surrounding structures. On subgroup analysis, anaerobic infection and diabetes were significantly associated with amputations. Post-operative oral antibiotics and immediate discharge may be considered for PFT after adequate surgical debridement with close outpatient follow-up in the absence of surrounding structure involvement and diabetes.
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Brewer CF, Akhavani M. Prognostic Factors for Repeated Flexor Tenosynovitis Washout: A Retrospective Study. J Hand Microsurg 2022; 14:345-346. [PMID: 36398163 PMCID: PMC9666064 DOI: 10.1055/s-0040-1715556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
| | - Mo Akhavani
- Department of Plastic Surgery, Royal Free Hospital, London, United Kingdom
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12
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Dujeux C, Cottebrune T, Malherbe M, Michon J, Fournier A, Hulet C. Use of antibiotics in pyogenic flexor tenosynovitis. HAND SURGERY & REHABILITATION 2022; 41:624-630. [PMID: 35933026 DOI: 10.1016/j.hansur.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/21/2022] [Accepted: 07/27/2022] [Indexed: 06/15/2023]
Abstract
Pyogenic flexor tenosynovitis is a frequent and serious condition. However, there is no consensus on the use of antibiotics. The objective of our study was to describe the treatment of this condition and to identify the surgical and medical management parameters to propose an effective and consensual postoperative antibiotic therapy protocol. We retrospectively reviewed pyogenic flexor tenosynovitis of the thumb or fingers treated between 01/01/2013 and 01/01/2018 at a teaching hospital. Inclusion criteria were confirmation of the clinical diagnosis intraoperatively and a minimum post-antibiotic follow-up of 6 months. Comorbidities, type of surgery, antibiotic therapy parameters, and treatment outcome were assessed. One hundred and thirteen patients were included. Fifty-four percent had comorbidities. The most frequent germ was staphylococcus, all patients received postoperative antibiotic therapy. Intravenous or intravenous followed by oral administration did not provide any benefit compared to an exclusively oral treatment (p = 0.46). The duration of postoperative antibiotic therapy (less than 7 days, between 7 and 14 days or more than 14 days) did not lead to any difference in healing rate (p = 0.67). However, treating for less than 7 days versus 7-14 days seemed to be associated with a higher risk of failure, although not statistically significant. Oral postoperative antibiotic therapy with amoxicillin + clavulanic acid for 7-14 days appears to be effective, allowing for outpatient management.
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Affiliation(s)
- C Dujeux
- Department of Orthopedic and Trauma Surgery, Caen University Hospital, Avenue de la côte de Nacre, 14000 Caen, France.
| | - T Cottebrune
- Department of Orthopedic and Trauma Surgery, Caen University Hospital, Avenue de la côte de Nacre, 14000 Caen, France
| | - M Malherbe
- Department of Orthopedic and Trauma Surgery, Caen University Hospital, Avenue de la côte de Nacre, 14000 Caen, France
| | - J Michon
- Department of Infectious Diseases, Caen University Hospital, Avenue de la côte de Nacre, 14000 Caen, France
| | - A Fournier
- Department of Infectious Diseases, Caen University Hospital, Avenue de la côte de Nacre, 14000 Caen, France
| | - C Hulet
- Department of Orthopedic and Trauma Surgery, Caen University Hospital, Avenue de la côte de Nacre, 14000 Caen, France
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A1 Pulley Tenderness as a Modification to Tenderness along the Flexor Sheath in Diagnosing Pyogenic Flexor Tenosynovitis. Plast Reconstr Surg Glob Open 2022; 10:e4165. [PMID: 35261842 PMCID: PMC8893286 DOI: 10.1097/gox.0000000000004165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/04/2022] [Indexed: 11/26/2022]
Abstract
Background: Pyogenic flexor tenosynovitis (PFT) is frequently diagnosed by physical examination according to the Kanavel signs. This study proposes a modification of the Kanavel sign “tenderness over the course of the flexor sheath” by including palpation of the A1 pulley to increase specificity for diagnosis. Methods: A retrospective review was performed over 8 months for patients in the emergency department who received a consult to hand surgery to rule out PFT. Two cohorts, nonPFT infections and PFT infections, were studied for the presence or absence of the four Kanavel signs, as well as tenderness specifically over the A1 pulley on the affected digit(s) or T1 pulley of the thumb. Results: There were a total of 33 patients in the two cohorts (21 nonPFT, 12 PFT) with statistically significant differences with regard to the presence of all the Kanavel signs. A1 pulley tenderness had the greatest odds ratio, positive predictive value, specificity, and accuracy when compared with all Kanavel signs. When used in conjunction with each Kanavel sign, there was an increase in specificity in all four signs. Receiver operating characteristic analysis revealed increased area under the curve with A1 pulley tenderness added, indicating improved ability to classify hand infections as PFT versus nonPFT. Conclusion: Although the classic Kanavel signs have shown reliable clinical utility, this study finds that tenderness at the A1 pulley can be a useful specification of “tenderness over the course of the flexor sheath” to help with the diagnosis of PFT.
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Ederer I, Schreiner J, Stahl S, Daigeler A, Wahler T. Role of antibiotic treatment after surgical debridement of superficial hand infection in 180 patients. HAND SURGERY & REHABILITATION 2022; 41:384-390. [DOI: 10.1016/j.hansur.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/09/2022] [Accepted: 02/12/2022] [Indexed: 10/18/2022]
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Lemme NJ, Li NY, Testa EJ, Kuczmarski AS, Modest J, Katarincic JA, Gil JA. A Nationwide Epidemiological Analysis of Finger Infections Presenting to Emergency Departments in the United States From 2012 to 2016. Hand (N Y) 2022; 17:302-307. [PMID: 32354232 PMCID: PMC8984722 DOI: 10.1177/1558944720915614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: There is a paucity of literature exploring the epidemiology of finger infections presenting to emergency departments (EDs) on a national scale. The purpose of this study was to determine the national incidence of and risk factors for finger infections. Methods: Finger infections presenting to EDs between 2012 and 2016 were identified in the National Electronic Injury Surveillance System database. Finger infections were characterized by mechanism and type, with subanalyses for sex, race, and age. Results: Over this 5-year period, finger infections accounted for 80 519 visits to EDs in the United States. The annual incidence increased significantly from 4.4 per 100 000 person-years in 2012 to 6.2 in 2016. The 3 most common causes of finger infections were nail manicuring tools, knives, and doors. The most common diagnosis was finger cellulitis (46.3%). Significantly more men developed finger infections than women (relative risk of 1.4). The highest overall incidence was observed in 40- to 59-year-old men (7.8 per 100 000 person-years). Tenosynovitis resulted in the largest proportion of admissions (25%). Conclusions: We have demonstrated a rising incidence of finger infections presenting to EDs, with 40- to 59-year-old patients most at risk. The most common mechanism was the use of nail manicuring tools, such as nail clippers. Patient education may decrease finger infection incidence from these activities, and early detection of finger infections may be crucial to minimizing hospital admissions and invasive treatments.
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Affiliation(s)
- Nicholas J. Lemme
- Alpert Medical School of Brown
University, Providence, RI, USA,Nicholas J. Lemme, Department of Orthopaedic
Surgery, Alpert Medical School of Brown University, 593 Eddy Street, Providence,
RI 02903, USA.
| | - Neill Y. Li
- Alpert Medical School of Brown
University, Providence, RI, USA
| | - Edward J. Testa
- Alpert Medical School of Brown
University, Providence, RI, USA
| | | | - Jacob Modest
- Alpert Medical School of Brown
University, Providence, RI, USA
| | | | - Joseph A. Gil
- Alpert Medical School of Brown
University, Providence, RI, USA
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16
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A Simple Technique to Facilitate Sheath Irrigation of Septic Flexor Tenosynovitis. Tech Orthop 2021. [DOI: 10.1097/bto.0000000000000507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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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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18
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Pillukat T, Rahimli M, Windolf J, van Schoonhoven J. Die Spül-Saug-Drainage zur Therapie der septischen Tenosynovialitis der Fingerbeugesehnen. HANDCHIR MIKROCHIR P 2021; 53:276-281. [PMID: 34134164 DOI: 10.1055/a-1408-4147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND/PURPOSE Pyogenic flexor tenosynovitis within the flexor tendon sheath requires urgent treatment to avoid tendon necrosis and loss of the finger. Objective of this article is the treatment by revision and postoperative continuous irrigation via a closed irrigation system. PATIENTS AND METHODS From 1.1.2007 to 31.12.2016 54 patients with a pyogenic flexor tenosynovitis were treated by revision and closed continuous irrigation. Besides the evaluation of the patient´s records with respect to the involved fingers and hand, duration of hospitalisation, and required revision surgery, 33 patients (19 males, 14 females) with an average age of 51 (8-85) years were re-examined on average after 21 (4-38) months. Re-examination included measurements of the mobility of the involved fingers and thumbs, grip and pinch strength, pain using the numeric rating scale (BRS), and DASH score. The overall result was graded according to the grading system by Buck-Gramcko for flexor tendon reconstruction. RESULTS Hospital stay was 9 (3-26) days on average. In 11 patients revision surgery was required including 3 re-installations of the continuous irrigation system, 2 ray amputations, and 1 finger amputation at the level of the proximal interphalangeal joint. The re-examined patients averaged a grip strength of 84 (23-163) % of the unaffected side. On average pain at rest was 0,2 (0-4), pain at daily living activity 1,2 (0-8) on the NRS, the DASH score 16,8 (0-58) points. According to the rating system for flexor tendon function there were one poor, one fair, 5 good and 26 excellent results. CONCLUSIONS Continuous irrigation by a closed irrigation system for pyogenic flexor tenosynovitis is a successful procedure with a low amputation rate. The functional results are predominantly good and excellent.
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Affiliation(s)
| | - M Rahimli
- Klinik für Handchirurgie Bad Neustadt an der Saale
| | - J Windolf
- Klinik für Unfall- und Handchirurgie, Universitätsklinikum Düsseldorf
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19
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Abstract
While many hand infections are superficial, diligent evaluation, diagnosis, and treatment of these infections are central for preventing disability and morbidity. Maintaining a wide differential diagnosis is important as some hand infections may mimic others. In geographic areas with more than a 10% to 15% prevalence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) hand infections, empiric antibiotics should adequately cover MRSA. Once culture results are available, antibiotic regimens should be narrowed to reduce the development of resistant pathogens.
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Affiliation(s)
- Vivek K Bilolikar
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Asif M Ilyas
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania.,Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
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20
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Mansour O, Moussa MK, Khalaf Z, Zreik H, Bou Raad R. Tuberculous Extensor Tenosynovitis Presenting as Huge Mass on the Dorsum of the Hand. Cureus 2020; 12:e10236. [PMID: 33042677 PMCID: PMC7535947 DOI: 10.7759/cureus.10236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Infectious tuberculous tenosynovitis (TS) of the extensor tendons of the wrist is an exceptional location of musculoskeletal tuberculosis. We present a case of tuberculous extensor TS in a 52-year-old diabetic male patient presenting as a huge mass on the dorsum of the hand, in the absence of other pulmonary or extrapulmonary manifestation of tuberculosis. This report increases physicians’ vigilance when dealing with patients with risk factors of tuberculosis, allowing early diagnosis and optimal treatment.
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Affiliation(s)
- Oussama Mansour
- Orthopedics and Traumatology, Al Zahraa Hospital, University Medical Center, Beirut, LBN
| | - Mohamad K Moussa
- Orthopedic Surgery, Lebanese University Faculty of Medical Science, Beirut, LBN
| | - Zaynab Khalaf
- Endocrinology, Diabetes and Metabolism, Lebanese University Faculty of Medical Science, Beirut, LBN
| | - Hussein Zreik
- Orthopaedics and Trauma, Al Zahraa Hospital, University Medical Center, Beirut, LBN
| | - Ryan Bou Raad
- Orthopaedics and Traumatology, Lebanese University Faculty of Medicine, Beirut, LBN
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21
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Rekant MS, Tarr R. Hand Abscesses: Volar and Dorsal. Hand Clin 2020; 36:307-312. [PMID: 32586456 DOI: 10.1016/j.hcl.2020.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A high index of suspicion coupled with excellent knowledge of hand anatomy and function allows for accurate diagnosis and effective management of deep space infections. This article describes surgical approaches for closed-space infections. Drainage, debridement, and intraoperative irrigation are initial steps along with the decision for continuous postoperative irrigation based on intraoperative findings. Focused and thorough postoperative evaluation and antibiotics lead to successful management of these soft tissue deep abscesses. An experienced hand therapist should be involved early in recovery process to guide wound care along with passive assisted and active range of motion exercises of the wrist and digits.
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Affiliation(s)
- Mark S Rekant
- Philadelphia Hand to Shoulder Center, Philadelphia, PA 19107, USA; Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA; Patricia Lincke, 1888 Marlton Pike East, Suite E, Cherry Hill, NJ 08057, USA.
| | - Ryan Tarr
- Philadelphia Hand to Shoulder Center, The Franklin, Suite G114, 834 Chestnut Street, Philadelphia, PA 19107, USA
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22
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Abstract
Pyogenic flexor tenosynovitis is a closed-space infection that can lead to a devastating loss of finger and hand function. It can spread rapidly into the palm, distal forearm, other digits, and nearby joints. Healthy individuals may present with no signs of systemic illness and often deny any penetrating trauma or inoculation. Early diagnosis and prompt treatment are required to preserve the digit and prevent morbidity and loss of hand function. Many treatment options have been described, although all share 2 common principles: evacuation of the infection and tailored postoperative antibiotic treatment with close monitoring to ensure clinical improvement.
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Affiliation(s)
- Kanu Goyal
- Department of Orthopaedic Surgery, Hand & Upper Extremity Center, The Ohio State Wexner Medical Center, 915 Olentangy River Road, Suite 3200, Columbus, OH 43212, USA.
| | - Amy L Speeckaert
- Department of Orthopaedic Surgery, Hand & Upper Extremity Center, The Ohio State Wexner Medical Center, 915 Olentangy River Road, Suite 3200, Columbus, OH 43212, USA
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23
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Dastagir K, Vehling M, Könneker S, Bingoel AS, Kaltenborn A, Jokuszies A, Vogt PM. Spread of Hand Infection According to the Site of Entry and Its Impact on Treatment Decisions. Surg Infect (Larchmt) 2020; 22:318-325. [PMID: 32735480 DOI: 10.1089/sur.2020.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Hand infections can spread quickly and destroy functional structures. Early diagnosis and adequate therapy can prevent severe morbidities. The aim of this study was to evaluate systematically the spread of hand infections according to injury mechanism, pathogens, and entry site. Methods: The data and medical records of 425 patients were collected and analyzed retrospectively. Results: The entry site had a significant influence on the severity of hand infections. Especially finger lesions led to severe infections. Furthermore, a high C-reactive protein (CRP) concentration correlated with more involved compartments of the hand. Bacterial counts also correlated with the number of compartments involved. Conclusions: Compared with known factors for the severity of hand infections finger lesions lead to especially severe infections and should not be underestimated. If there is a higher CRP concentration or more than one bacterial species isolated, compartments adjacent to the site of injury should be checked intra-operatively.
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Affiliation(s)
- Khaled Dastagir
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Medical School Hannover, Hannover, Germany
| | - Malte Vehling
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Medical School Hannover, Hannover, Germany
| | - Sören Könneker
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Medical School Hannover, Hannover, Germany
| | - Alperen Sabri Bingoel
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Medical School Hannover, Hannover, Germany
| | - Alexander Kaltenborn
- Department of Trauma and Orthopedic Surgery, Plastic, Hand and Reconstructive Surgery, Armed Forces Hospital Westerstede, Westerstede, Germany
| | - Andreas Jokuszies
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Medical School Hannover, Hannover, Germany
| | - Peter Maria Vogt
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Medical School Hannover, Hannover, Germany
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24
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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: 10] [Impact Index Per Article: 2.5] [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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25
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Nimjareansuk W, Rosselli M. Pyogenic Flexor Tenosynovitis as a Rare Complication of Dyshidrotic Eczema. Clin Pract Cases Emerg Med 2020; 4:174-177. [PMID: 32426665 PMCID: PMC7220023 DOI: 10.5811/cpcem.2020.1.45414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 01/04/2020] [Accepted: 01/23/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction: Pyogenic flexor tenosynovitis is an unusual complication of dyshidrotic eczema. The diagnosis has traditionally been made by Kanavel’s signs. Point-of-care ultrasound can be a useful adjunct in the diagnosis of this surgical emergency.
Case Report: We report the case of a 23-year-old male who presented with right middle finger pain and swelling and an overlying eczematous rash. The use of point-of-care ultrasound was performed to aid in the diagnosis of pyogenic flexor tenosynovitis. An incision and drainage was performed with deep wound cultures positive for Staphylococcus aureus.
Discussion: The presentation of pyogenic flexor tenosynovitis with underlying concomitant dermatological disease can complicate this challenging diagnosis. Point-of-care ultrasound can be an effective adjunct in revealing pyogenic flexor tenosynovitis rather than relying solely on the classical Kanavel’s signs, leading to earlier treatment.
Conclusion: Our case demonstrates that point-of-care ultrasound can be a rapid and effective tool for the diagnosis of pyogenic flexor tenosynovitis in the setting of superimposed dermatological diseases.
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Affiliation(s)
- Waroot Nimjareansuk
- Mount Sinai Medical Center, Department of Emergency Medicine, Miami Beach, Florida
| | - Michael Rosselli
- Mount Sinai Medical Center, Department of Emergency Medicine, Miami Beach, Florida
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26
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Frenkel Rutenberg T, Velkes S, Sidon E, Paz L, Peylan J, Shemesh S, Iordache SD. Conservative treatment for pyogenic flexor tenosynovitis: a single institution experience. J Plast Surg Hand Surg 2019; 54:14-18. [DOI: 10.1080/2000656x.2019.1657434] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Tal Frenkel Rutenberg
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Steven Velkes
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eliezer Sidon
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lior Paz
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jacques Peylan
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shai Shemesh
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sorin Daniel Iordache
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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27
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Abstract
Hand infections can lead to debilitating and permanent disability, particularly if they are not treated promptly or properly. The unique anatomy of the hand, with its numerous enclosed and confined spaces, warrants special considerations. For instance, infections in deep spaces of the hand may require surgical drainage despite an appropriate course of antimicrobial treatment. Thorough history and examination are crucial in guiding further investigations and management, particularly because there are numerous mimickers of hand infections, such as gout and pseudogout.
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Affiliation(s)
- Wendy Z W Teo
- Department of Hand and Reconstructive Microsurgery, National University Health System, 1E Kent Ridge Road, Level 11, Singapore 119228, Singapore.
| | - Kevin C Chung
- The University of Michigan Health System, 1500 East Medical Center Drive, 2130 Taubman Center, SPC 5340, Ann Arbor, MI 48109-5340, USA
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28
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Abstract
Infections are common in hand surgery and proper management is important to achieve optimal outcomes. Although most cases are not urgent, less common, severe infections such as flexor tenosynovitis and necrotizing fasciitis require urgent identification with both medical and surgical management. It is common for diagnoses to be missed or delayed because clinical and laboratory indicators are often variably present. Delayed identification and management can result in poor outcomes with permanent deficits. This article will provide a review of hand infections with a focus on identifying serious hand infections requiring urgent or emergent treatment, and distinguishing these from less urgent scenarios.
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Affiliation(s)
- John C Koshy
- Division of Plastic Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Bryce Bell
- Department of Orthopedic Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX.
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29
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Hubbard D, Joing S, Smith SW. Pyogenic Flexor Tenosynovitis by Point-of-care Ultrasound in the Emergency Department. Clin Pract Cases Emerg Med 2018; 2:235-240. [PMID: 30083641 PMCID: PMC6075484 DOI: 10.5811/cpcem.2018.3.37415] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/25/2018] [Accepted: 03/28/2018] [Indexed: 11/11/2022] Open
Abstract
Introduction Pyogenic flexor tenosynovitis (PFT) is difficult to diagnose on clinical grounds alone as many patients requiring an operation do not have all four of Kanavel’s signs. Previous studies have shown that hypoechoic fluid surrounding the flexor tendon on ultrasound is associated with this diagnosis. We sought to determine if emergency physicians (EPs) could recognize this finding in patients with suspected flexor tenosynovitis using point-of-care ultrasound (POCUS). Methods We present a retrospective case series of seven patients suspected of PFT who had hypoechoic fluid surrounding the tendon on POCUS performed by the treating EP. We report on the patient characteristics, history of trauma by puncture wound, number of Kanavel’s signs, treatment course, and operative findings. Results We identified seven patients suspected to have flexor tenosynovitis by the emergency department attending physician who had anechoic or hypoechoic fluid surrounding the flexor tendon on real-time POCUS examination. Patients ranged in age from 16 – 51 years. All were male. All patients had at least two of Kanavel’s signs on examination. Five of seven (71%) patients had history of recent trauma to the affected hand. Four of seven (57%) were managed in the operating room. One of seven (14%) had incision and drainage at the bedside, and the remaining two (28%) were managed non-operatively and successfully with antibiotics alone. Conclusion Our study demonstrates that EPs can recognize the finding of hypoechoic or anechoic fluid surrounding the flexor tendon on POCUS.
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Affiliation(s)
- Daniel Hubbard
- Oregon Health & Science University, Department of Emergency Medicine, Portland, Oregon
| | - Scott Joing
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Steven W Smith
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota
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30
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Mamane W, Lippmann S, Israel D, Ramdhian-Wihlm R, Temam M, Mas V, Pierrart J, Masmejean EH. Infectious flexor hand tenosynovitis: State of knowledge. A study of 120 cases. J Orthop 2018; 15:701-706. [PMID: 29881224 PMCID: PMC5990318 DOI: 10.1016/j.jor.2018.05.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 05/06/2018] [Indexed: 10/16/2022] Open
Abstract
INTRODUCTION Since Kanavel in 1905, knowledge of phlegmon of flexor tendon sheaths of the fingers have evolved over the twentieth century. This serious infection is 20% of infections of the hand and may have adverse consequences for the function of the finger and even beyond, of the hand. Amputation is always a risk. Frequently face this type of infection, we conducted a retrospective study and made an inventory of knowledge in order to consolidate and improve the overall care. MATERIALS & METHODS The study was retrospective and cross, focused on 120 patients operated on at Hand Surgery Unit, during 4 years. Inclusion criteria were primary or secondary infection of the sheath of the flexor tendons of the fingers.The evaluation focused on clinical and paraclinical perioperative parameters. At last follow, digital mobility (Total Active Motion), the functional score of QuickDASH and the socio-professional consequences were evaluated. RESULTS The mean age was 40 years, with a male predominance. The hospital stay was 17 days on average (3 days to 80 days). From the classification of Michon, as amended by Sokolow, we found 60 Stage I, 48 stage II, 12 stage III. The Total Active Motion was respectively 240 °, 140 °, 40 °. QuickDASH scores were respectively 20, 56 and 90 out of 100. The time for return to work was 1 month for stage I, 4 months for stage II and 12 months for stage III. DISCUSSION The long-term functional outcome was generally poor, with stiffness or digital amputation. The poor prognostic factors were: the initial advanced stage of infection, infection beta-haemolytic Streptococcus group A, and delayed surgical management. Smoking was identified as a new risk factor in this disease, as well as diabetes or immunodeficiency. This study confirmed the predominance of Staphylococcus, and scalability of the infection depending on the mode of contamination, and / or type of germ that is to say, scalability schedule for β-hemolytic streptococci group A chronic and scalability for intracellular bacteria (mycobacteria). CONCLUSION Any suspicion of flexor hand tenosynovitis should lead to an emergency surgical exploration, not primary antibiotics prescription!
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Affiliation(s)
- William Mamane
- Hand & Upper Limb Unit, SOS Main/Clinique Floréal, 40 rue Floréal, 93170, Bagnolet, France
- Hand & Upper Limb Unit, SOS Main/Clinique Conti, 3 chemin des trois sources, 95290, L’Isle-Adam, France
- Hand & Upper Limb Unit, SOS Main/Hôpital Européen G. Pompidou, 20 rue Leblanc, 75015, Paris, France
| | - Stenley Lippmann
- Hand & Upper Limb Unit, SOS Main/Clinique Floréal, 40 rue Floréal, 93170, Bagnolet, France
- Department of Orthopedic Surgery, Hôpital Beaujon, 100 Bd du G.Leclerc, 92110, Clichy, France
| | - Dan Israel
- Hand & Upper Limb Unit, SOS Main/Clinique Floréal, 40 rue Floréal, 93170, Bagnolet, France
| | - Reeta Ramdhian-Wihlm
- Hand & Upper Limb Unit, SOS Main/Clinique Floréal, 40 rue Floréal, 93170, Bagnolet, France
| | - Michael Temam
- Hand & Upper Limb Unit, SOS Main/Clinique Conti, 3 chemin des trois sources, 95290, L’Isle-Adam, France
| | - Virginie Mas
- Hand & Upper Limb Unit, SOS Main/Clinique Conti, 3 chemin des trois sources, 95290, L’Isle-Adam, France
| | - Jérome Pierrart
- Hand & Upper Limb Unit, SOS Main/Hôpital Européen G. Pompidou, 20 rue Leblanc, 75015, Paris, France
| | - Emmanuel H. Masmejean
- Hand & Upper Limb Unit, SOS Main/Hôpital Européen G. Pompidou, 20 rue Leblanc, 75015, Paris, France
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31
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Jardin E, Delord M, Aubry S, Loisel F, Obert L. Usefulness of ultrasound for the diagnosis of pyogenic flexor tenosynovitis: A prospective single-center study of 57 cases. HAND SURGERY & REHABILITATION 2018; 37:95-98. [PMID: 29396150 DOI: 10.1016/j.hansur.2017.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 12/16/2017] [Accepted: 12/29/2017] [Indexed: 11/18/2022]
Abstract
Pyogenic flexor tenosynovitis (PFT) is a functional emergency in hand surgery; however, its diagnosis can be difficult to make. It should always be considered when a patient presents with an inflamed finger. The goal of this study was to investigate the usefulness of ultrasound in the diagnosis of early PFT. Seventy-three patients with suspected pyogenic flexor tenosynovitis were candidates for the study. Since the diagnosis of PFT was obvious in 16 patients, they were excluded from the study and immediately underwent surgery. The remaining 57 patients underwent a clinical examination by a senior surgeon, a blood test for C-reactive protein levels and an ultrasound (US). The US results were compared to the intraoperative findings if the patients were operated or to the clinical outcome in non-operated patients. Seventeen patients had the US diagnosis of PFT confirmed intraoperatively. In 10 patients, the US diagnosis of PFT was not confirmed intraoperatively. In 29 other patients, the diagnosis of PFT was ruled out by US; they all had good outcomes after being treated with antibiotics. In one patient for whom the diagnosis of PFT had been ruled out by US, PFT was actually present. Ultrasound had 94% sensitivity, 65% specificity, 63% positive predictive value, and 95% negative predictive value. Ultrasound is useful as a diagnostic tool for managing early PFT thanks to its excellent negative predictive value and specificity. This objective examination complements the surgeon's subjective clinical examination.
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Affiliation(s)
- E Jardin
- Clinique de Diaconat-Roosevelt-Service SOS Mains, 14, boulevard du Président Roosevelt, 68200 Mulhouse, France.
| | - M Delord
- Service de chirurgie orthopédique traumatologique plastique assistance main, CHU Jean-Minjoz, boulevard Alexandre-Fleming, 25000 Besançon, France.
| | - S Aubry
- Service de radiologie, CHU Jean-Minjoz, boulevard Alexandre-Fleming, 25000 Besançon, France.
| | - F Loisel
- Service de chirurgie orthopédique traumatologique plastique assistance main, CHU Jean-Minjoz, boulevard Alexandre-Fleming, 25000 Besançon, France.
| | - L Obert
- Service de chirurgie orthopédique traumatologique plastique assistance main, CHU Jean-Minjoz, boulevard Alexandre-Fleming, 25000 Besançon, France.
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Born TR, Wagner ER, Kakar S. Comparison of Open Drainage Versus Closed Catheter Irrigation for Treatment of Suppurative Flexor Tenosynovitis. Hand (N Y) 2017; 12:579-584. [PMID: 29091483 PMCID: PMC5669325 DOI: 10.1177/1558944716675131] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The purpose of this study was to review the outcomes associated with different surgical treatments in the management of suppurative flexor tenosynovitis (SFT). METHODS Patients treated by open drainage (OD) through a single incision and closed catheter irrigation (CCI) of the tendon sheath were evaluated from 2003 to 2009 at a single institution. Variables examined included culture results, time to surgery, duration of hospitalization and antibiotic therapy, pain, reoperation, and functional outcomes were recorded. Statistical analyses used included parametric and nonparametric t tests. RESULTS Twenty-four patients were treated for SFT with a mean follow-up of 3 ± 2 years. There were 13 (100%) males in the OD group compared to 8 (72%) males within the CCI group. Ninety-two percent of patients who underwent OD and 100% who underwent CCI reported none or mild pain. There were no differences between the 2 groups with regard to functional outcome scores. Factors leading to worse functional outcomes included prolonged time to receiving antibiotics and Staphylococcus aureus infection. Smokers required prolonged antibiotic treatment compared to nonsmokers. Accounting for planned returns to the operating room, there was no difference in reoperation rates between the OD or CCI groups. CONCLUSIONS Surgical treatment of SFT with either OD or CCI resulted in similar outcomes for pain, function, and need for reoperation. Factors that lead to poor outcomes include S aureus culture, prolonged time to antibiotics, and smoking.
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Affiliation(s)
| | | | - Sanjeev Kakar
- Mayo Clinic, Rochester, MN, USA,Sanjeev Kakar, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Kennedy CD, Lauder AS, Pribaz JR, Kennedy SA. Differentiation Between Pyogenic Flexor Tenosynovitis and Other Finger Infections. Hand (N Y) 2017; 12:585-590. [PMID: 28720000 PMCID: PMC5669334 DOI: 10.1177/1558944717692089] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hospital transfer decisions regarding pyogenic flexor tenosynovitis (PFT) are made difficult by emergency department presentations similar to other finger infections, with pain, redness, and functional limitation. Our objectives were to: (1) determine diagnostic sensitivity and specificity of Kanavel signs; and (2) identify existing factors most predictive of PFT during initial presentation. METHODS Adult patients who underwent surgical consultation for concern of PFT over a 5-year period were identified retrospectively. Bivariate screening identified clinical criteria for differentiation, and multivariate logistic regression was performed to control for confounding. We then created a prediction algorithm for diagnosis of PFT. Receiver operating characteristic (ROC) curve analysis was used to evaluate diagnostic accuracy. RESULTS Patients with PFT differed significantly from those with non-PFT finger infections in regard to the 4 Kanavel signs, duration of symptoms less than 5 days, and erythrocyte sedimentation rate. Sensitivity of the Kanavel signs ranged from 91.4% to 97.1%. Specificity ranged from 51.3% to 69.2%. Logistic regression identified independent predictors for PFT as tenderness along the flexor tendon sheath, pain with passive extension, and duration of symptoms less than 5 days. A prediction algorithm incorporating these 3 factors showed an area under the ROC curve of 0.91 (95% confidence interval, 0.840-0.979). CONCLUSIONS Kanavel signs have high sensitivity for detecting PFT but have poor specificity on an individual basis. Clinical prediction algorithms that combine the relevant factors may be helpful in the development of clinical prediction tools and educational materials for optimization of emergency hand care systems. Further prospective study is needed.
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Affiliation(s)
- Colin D. Kennedy
- University of Washington Medical Center/Harborview Medical Center, Seattle, USA,Colin D. Kennedy, Resident Physician, Department of Orthopaedics and Sports Medicine, University of Washington, 325 Ninth Avenue, Box 359798, Seattle, WA 98104, USA.
| | - Alexander S. Lauder
- University of Washington Medical Center/Harborview Medical Center, Seattle, USA
| | - Jonathan R. Pribaz
- University of Washington Medical Center/Harborview Medical Center, Seattle, USA
| | - Stephen A. Kennedy
- University of Washington Medical Center/Harborview Medical Center, Seattle, USA
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Abstract
Pyogenic tenosynovitis is an uncommon condition in children, and there are few published case reports. We present a series of 11 cases who were treated in the Geneva Children Hospital in the last 10 years. Kingella kingae was the main pathogen, and the characteristics of infection (inflammatory indices, clinical findings and severity) are similar to other osteoarticular K. kingae infections in infants.
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Knackstedt R, Tyler J, Bernard S. Closed Continuous Irrigation With Lidocaine and Immediate Mobilization for Treatment of Pyogenic Tenosynovitis. Tech Hand Up Extrem Surg 2017; 21:114-115. [PMID: 28727585 DOI: 10.1097/bth.0000000000000164] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Pyogenic flexor tenosynovitis treatment consists of either closed continuous irrigation with sterile saline or antibiotic solution, or open debridement and irrigation. These treatment approaches serve to resolve the infection, but are extremely painful and residual stiffness can be devastating to the patient. We describe herein our approach to managing pyogenic flexor tenosynovitis. To provide continuous irrigation, a butterfly catheter with needle removed is utilized with irrigation holes cut into the tubing. The catheter is inserted into the tendon sheath at the level of the Al pulley and brought out at the level of the A5 pulley. A knot is tied in the end of the catheter for retention, eliminating the need for sutures. Immediately postoperative, continuous irrigation with sterile saline mixed with lidocaine is initiated and is titrated to achieve pain-free motion in the finger. Occupational therapy begins an aggressive course of active and passive range of motion exercises immediate postoperatively, which is continued for the remainder of hospitalization. Our approach of continuous infusion of a lidocaine solution allows for pain-free movement immediately postoperatively to mechanically debride tissue, as well as allow for early active range of motion. We have obtained excelleepaknt results with this technique in all of our cases.
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Affiliation(s)
- Rebecca Knackstedt
- *Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Division of Plastic and Hand Surgery †MetroHealth Medical Center, Cleveland, OH
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Harris AP, Johnson J, Kluk A, Li NY, Goodman AD, Akelman E. Polymicrobial pyogenic flexor tenosynovitis of the index finger and first ray resulting from autophagia. J Orthop 2017; 14:403-405. [PMID: 28725123 DOI: 10.1016/j.jor.2017.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 06/22/2017] [Indexed: 11/24/2022] Open
Abstract
Pyogenic flexor tenosynovitis (PFT) is a well known infectious condition of the hand, involving the inoculation of the flexor tendon sheath with microorganisms. Many cases have been reported, common causes including direct inoculation by a puncture wound and deep lacerations extending into the flexor tendon sheath. In this report, we present a case of a 50 year old female with PFT resulting from autophagia (consuming one's own body parts, in our case, fingers) successfully treated with irrigation and debridement, amputation of the index finger at the metacarpophalangeal joint and antibiotic therapy.
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Affiliation(s)
- Andrew P Harris
- Department of Orthopaedics,Alpert Medical School of Brown University, Providence, RI, United States
| | - Joey Johnson
- Department of Orthopaedics,Alpert Medical School of Brown University, Providence, RI, United States
| | - Augusta Kluk
- Department of Orthopaedics,Alpert Medical School of Brown University, Providence, RI, United States
| | - Neill Y Li
- Department of Orthopaedics,Alpert Medical School of Brown University, Providence, RI, United States
| | - Avi D Goodman
- Department of Orthopaedics,Alpert Medical School of Brown University, Providence, RI, United States
| | - Edward Akelman
- Department of Orthopaedics,Alpert Medical School of Brown University, Providence, RI, United States
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Brusalis CM, Thibaudeau S, Carrigan RB, Lin IC, Chang B, Shah AS. Clinical Characteristics of Pyogenic Flexor Tenosynovitis in Pediatric Patients. J Hand Surg Am 2017; 42:388.e1-388.e5. [PMID: 28341068 DOI: 10.1016/j.jhsa.2017.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 01/31/2017] [Accepted: 02/10/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To characterize the clinical presentation, common pathogens, antimicrobial susceptibility, and treatment methods associated with pyogenic flexor tenosynovitis (PFT) in pediatric patients. METHODS Patients who underwent surgical treatment for PFT at a large tertiary-care children's hospital between 2001 and 2015 were identified. Descriptive summary statistics were reported on patient demographics, presenting symptoms and clinical examination features, culture results, treatment strategies, and early complications. RESULTS Thirty-two patients (71.9% male) with a mean age of 9.5 ± 5.5 years (range, 0.8-19 years) were included. At least 3 Kanavel signs were present on presentation in 62% of the cohort, with all 4 signs identified in 34%. Three children (9%) presented with 0 to 1 Kanavel signs, with semiflexed posturing of the digit as the least commonly (41%) manifested sign. The most frequently cultured organisms were methicillin-resistant Staphylococcus aureus (MRSA) (38%), methicillin-sensitive S. aureus (22%), and Pasteurella multocida (13%). Multiple organisms were cultured in 19% of cases. Intravenous antibiotics were administered for a median duration of 4 days (range, 1-16 days) in all cases. Organisms were sensitive to the initial antibiotic regimen in 81% of cases. All methicillin-resistant S. aureus infections were sensitive to vancomycin and trimethroprim-sulfamethoxazole, and 83% were sensitive to clindamycin. Incision and drainage (I&D) was performed in all cases, with 18% of patients requiring repeat I&D. Surgical approaches included limited incision (80%), midaxial incision (13%), and Bruner incision (7%). The average length of hospitalization was 5.1 days. Infection resolved in all cases without readmission. No neurovascular complications were identified. CONCLUSIONS The presence of Kanavel signs at presentation are a meaningful indicator of PFT, but are not uniformly present on examination in children and adolescents. Owing to the prevalence of antimicrobial resistance and polymicrobial infection, empirical antibiotic therapy using broad-spectrum agents with MRSA coverage is essential. In our cohort of pediatric patients with PFT of sufficient severity to warrant surgical management, prompt I&D along with culture-guided antibiotics predictably resolves infection. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Christopher M Brusalis
- Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Stephanie Thibaudeau
- Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania; and the Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Robert B Carrigan
- Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ines C Lin
- Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania; and the Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Benjamin Chang
- Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania; and the Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Apurva S Shah
- Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA.
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Abstract
For patients with suspected flexor tenosynovitis, the mainstay of diagnosis is a thorough history and physical examination. The examination is guided by evaluating the patient for Kanavel's four cardinal signs. Empiric antibiotics should be started immediately on diagnosis covering skin flora and gram-negative bacteria. Typically, surgery is required. Appropriate exposure is required for adequate treatment and incisions should be tailored to preserve areas of skin compromised from draining sinuses and abscess pressure. Diabetes mellitus and peripheral vascular disease place patients at higher risk of poor outcomes including stiffness and amputation; early administration of antibiotics is the intervention that correlates most closely with good outcomes.
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Affiliation(s)
- Brad T Hyatt
- The Hand Center of San Antonio, 21 Spurs Lane, San Antonio, TX 78240, USA.
| | - Mark R Bagg
- The Hand Center of San Antonio, 21 Spurs Lane, San Antonio, TX 78240, USA
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An Easy Method for Drainage of Fluid in Cases of Continuous Irrigation of the Hand. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 4:e1127. [PMID: 28293498 PMCID: PMC5222643 DOI: 10.1097/gox.0000000000001127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 09/20/2016] [Indexed: 11/27/2022]
Abstract
Description of a novel method to perform continuous irrigation for flexor tenosynovitis in a way that is comfortable for the patient and convenient for nursing staff by placing the hand in the suction pouch of a lithotomy style drape attached to wall suction.
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40
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Hohendorff B, Sauer H, Biber F, Franke J, Spies CK, Müller LP, Ries C. Treatment of digital pyogenic flexor tenosynovitis: single open debridement, irrigation, and primary wound closure followed by antibiotic therapy. Arch Orthop Trauma Surg 2017; 137:141-145. [PMID: 27787635 DOI: 10.1007/s00402-016-2587-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Digital pyogenic flexor tenosynovitis requires fast, aggressive treatment. Although this infection occurs frequently, treatment consensus is lacking. MATERIALS AND METHODS Between 2011 and 2015, 22 patients with acute pyogenic flexor tenosynovitis were treated with a single open debridement followed by irrigation; the incision was closed and a 10-day antibiotic course was administered. The average incision-to-suture time was 25 min, and the average hospital stay was 4 days. Recovery was uncomplicated for 20 patients, while two were reoperated, one due to germ resistance and the other due to necrotizing fasciitis. At an average of 30 month postoperatively, 21 of the 22 patients were available for follow-up. The affected finger was inspected, and sensibility, range of motion, and grip force were compared with the opposite side, and the DASH score was determined. Each patient documented pain in the affected finger at rest and during activity, and rated overall satisfaction with the treatment on a visual analogue scale. RESULTS Almost all patients were free of pain at follow-up and very satisfied. Compared to the contralateral side, each of the affected fingers had the same range of motion and sensibility. Grip force was similar on both sides. The average DASH score was 35 points. CONCLUSION A single open debridement with irrigation and primary wound closure followed by 10 days of antibiotic treatment resolved uncomplicated pyogenic flexor tenosynovitis. After 2 and a half years, the treatment yielded high patient satisfaction with neither functional nor subjective impairment of the affected finger.
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Affiliation(s)
- Bernd Hohendorff
- Abteilung für Hand-, Ästhetische und Plastische Chirurgie, Elbe Klinikum Stade, Stade, Germany.
| | - H Sauer
- Abteilung für Hand-, Ästhetische und Plastische Chirurgie, Elbe Klinikum Stade, Stade, Germany
| | - F Biber
- Abteilung für Hand-, Ästhetische und Plastische Chirurgie, Elbe Klinikum Stade, Stade, Germany
| | - J Franke
- Klinik für Unfallchirurgie und Orthopädie, Elbe Klinikum Stade, Stade, Germany
| | - C K Spies
- Handchirurgie, Vulpius Klinik, Bad Rappenau, Germany
| | - L P Müller
- Unfall-, Hand- und Ellenbogenchirurgie, Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum zu Köln, Cologne, Germany
| | - C Ries
- Unfall-, Hand- und Ellenbogenchirurgie, Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum zu Köln, Cologne, Germany
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41
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Thomson CH, McMullan M, Williams N. Critical factors in managing flexor sheath infection. J Plast Reconstr Aesthet Surg 2016; 70:140-141. [PMID: 27292290 DOI: 10.1016/j.bjps.2016.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 05/22/2016] [Indexed: 11/26/2022]
Affiliation(s)
- C H Thomson
- Department of Plastic Surgery, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK.
| | - M McMullan
- Department of Plastic Surgery, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
| | - N Williams
- Department of Plastic Surgery, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
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In Brief: Kanavel's Signs and Pyogenic Flexor Tenosynovitis. Clin Orthop Relat Res 2016; 474:280-4. [PMID: 26022113 PMCID: PMC4686527 DOI: 10.1007/s11999-015-4367-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 05/19/2015] [Indexed: 01/31/2023]
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Giladi AM, Malay S, Chung KC. A systematic review of the management of acute pyogenic flexor tenosynovitis. J Hand Surg Eur Vol 2015; 40:720-8. [PMID: 25670687 PMCID: PMC4804717 DOI: 10.1177/1753193415570248] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 01/05/2015] [Indexed: 02/03/2023]
Abstract
UNLABELLED Pyogenic flexor tenosynovitis (PFT) is an aggressive closed-space infection that can result in severe morbidity. Although surgical treatment of pyogenic flexor tenosynovitis has been widely described, the role of antibiotic therapy is inadequately understood. We conducted a literature review of studies reporting on acute pyogenic flexor tenosynovitis management. A total of 28 case series articles were obtained, all of which used surgical intervention with varied use of antibiotics. Inconsistencies among the studies limited summative statistical analysis. Our results showed that use of antibiotics as a component of therapy resulted in improved range of motion outcomes (54% excellent vs. 14% excellent), as did using catheter irrigation rather than open washout (71% excellent vs. 26% excellent). These studies showed benefits of early treatment of pyogenic flexor tenosynovitis and of systemic antibiotic use. As broad-spectrum antibiotics have changed the management of other infectious conditions, we must more closely evaluate consistent antibiotic use in pyogenic flexor tenosynovitis management. LEVEL OF EVIDENCE Therapeutic, Level III.
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Affiliation(s)
- Aviram M. Giladi
- Resident, Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System
| | - Sunitha Malay
- Clinical Research Coordinator, Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System
| | - Kevin C. Chung
- Professor of Surgery, Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System
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Karagergou E, Rao K, Harper RD. Parameters affecting the severity and outcome of pyogenic digital flexor tenosynovitis. J Hand Surg Eur Vol 2015; 40:100-1. [PMID: 24401736 DOI: 10.1177/1753193413517203] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- E Karagergou
- Sheffield Hand Centre, Plastic Surgery Department, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
| | - K Rao
- Sheffield Hand Centre, Plastic Surgery Department, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
| | - R D Harper
- Sheffield Hand Centre, Plastic Surgery Department, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
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Patel DB, Emmanuel NB, Stevanovic MV, Matcuk GR, Gottsegen CJ, Forrester DM, White EA. Hand Infections: Anatomy, Types and Spread of Infection, Imaging Findings, and Treatment Options. Radiographics 2014; 34:1968-86. [DOI: 10.1148/rg.347130101] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Osterman M, Draeger R, Stern P. Acute hand infections. J Hand Surg Am 2014; 39:1628-35; quiz 1635. [PMID: 25070032 DOI: 10.1016/j.jhsa.2014.03.031] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 03/24/2014] [Accepted: 03/25/2014] [Indexed: 02/02/2023]
Abstract
The continued emergence of antibiotic-resistant bacteria and the development of only a few new classes of antibiotics over the past 50 years have made the treatment of acute hand infections problematic. Prompt diagnosis and treatment are important, because hand stiffness, contractures, and even amputation can result from missed diagnoses or delayed treatment. The most common site of hand infections is subcutaneous tissue and the most common mechanism is trauma. An immunocompromised state, intravenous drug abuse, diabetes mellitus, and steroid use all predispose to infections.
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Affiliation(s)
- Meredith Osterman
- Mary S. Stern Hand Fellow, Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.
| | - Reid Draeger
- Mary S. Stern Hand Fellow, Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Peter Stern
- Mary S. Stern Hand Fellow, Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
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47
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Reinus WR, De Cotiis D, Schaffer A. Changing patterns of septic tenosynovitis of the distal extremities. Emerg Radiol 2014; 22:133-9. [DOI: 10.1007/s10140-014-1258-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 07/17/2014] [Indexed: 10/25/2022]
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48
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Bishop GB, Born T, Kakar S, Jawa A. The diagnostic accuracy of inflammatory blood markers for purulent flexor tenosynovitis. J Hand Surg Am 2013; 38:2208-11. [PMID: 24206985 DOI: 10.1016/j.jhsa.2013.08.094] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Revised: 08/07/2013] [Accepted: 08/07/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE For patients with purulent flexor tenosynovitis, our purpose was to (1) calculate the diagnostic accuracy of white blood count (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) for those who underwent surgical drainage, (2) to correlate these markers for those treated with antibiotics alone, and (3) to evaluate the accuracy of diagnosis for surgical patients. METHODS A total of 82 consecutive patients (71 surgical and 11 nonsurgical) with flexor tenosynovitis were identified from orthopedic databases at 2 academic centers. We evaluated inflammatory markers (WBC, ESR, and CRP), radiographs, descriptions of surgical findings, and intraoperative cultures for all patients. For nonsurgical patients, we evaluated inflammatory markers for possible correlation with the presumed diagnosis of purulent flexor tenosynovitis. For surgical patients, sensitivity, specificity, positive predictive value, and negative predictive value were calculated individually for inflammatory markers. RESULTS For nonsurgical patients, WBC, ESR, and CRP were elevated in 3 of 11 patients (27%), 6 of 8 patients (75%), and 6 of 7 patients (86%), respectively. For surgical patients, the intraoperative findings or cultures were consistent with infection in 69 of 71 cases (97%), whereas calcific tendinitis was diagnosed in 2 cases. Cultures were positive in 56 patients (79%). All 3 markers had a specificity and positive predictive value of 100%. For WBC, ESR, and CRP, respectively, the sensitivity was 39%, 41%, and 76% and the negative predictive value was 4%, 3%, and 13%. CONCLUSIONS Commonly used inflammatory blood markers (WBC, ESR, and CRP) may be helpful in diagnosing purulent flexor tenosynovitis. If the levels of any of these markers are elevated in patients suspected of having the diagnosis, the likelihood of infection is extremely high. However, with low negative predictive values, these markers cannot reliably rule out infection. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic III.
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Affiliation(s)
- Gavin B Bishop
- Department of Orthopedic Surgery, Boston University Medical Center, Boston, MA; Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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Two-stage tendon sheath reconstruction using sublimis tendon and silicone Penrose drain after severe purulent flexor tenosynovitis: a case report. Hand (N Y) 2013; 8:343-7. [PMID: 24426946 PMCID: PMC3745240 DOI: 10.1007/s11552-013-9507-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Two-stage tendon sheath reconstruction, a method of pulley reconstruction using the sublimis tendon and a pseudosheath formed with a silicone Penrose drain wrapped around the profundus tendon, is a new technique for improving a poor functional prognosis after purulent flexor tenosynovitis.
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50
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Langer MF, Surke C, Wieskötter B. Die Beugesehnenscheideninfektion der Finger und des Daumens. ACTA ACUST UNITED AC 2013. [DOI: 10.1007/s11678-013-0223-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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