Septic arthritis of the hand: Current issues of etiology, pathogenesis, diagnosis, treatment

High risk and low prevalence diseases: Flexor tenosynovitis

INTRODUCTION

Flexor tenosynovitis (FTS) is a deep space infection of an upper extremity digit which carries a high rate of morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of FTS, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

FTS typically occurs after direct penetrating trauma to the volar aspect of an upper extremity digit. Development of a deep space infection that quickly propagates through the flexor tendon sheath of a digit can result in serious structural damage to the hand and place the patient at risk for significant morbidity such as finger amputation or even result in death. Signs of FTS include symmetrical swelling of the affected finger, the affected finger being held in a flexed position, pain on any attempt of passive finger extension, and tenderness along the course of flexor tendon sheath, known as the Kanavel signs. Systemic symptoms such as fevers and chills may occur. Recognition of these signs and symptoms is paramount in diagnosis of FTS, as laboratory and imaging assessment is not typically diagnostic. ED management involves intravenous antibiotics and emergent surgical specialist consultation.

CONCLUSION

An understanding of the presentation and risk factors for development of FTS can assist emergency clinicians in diagnosing and managing this disease in an expedited fashion.

Two-stage reconstruction using a vancomycin-impregnated cement spacer for finger osteomyelitis with bone and joint destruction

OBJECTIVES

Septic arthritis and osteomyelitis are serious infections. Several treatment methods for the small joints and bones of the hands have been reported. We hypothesized that antibiotic-impregnated cement spacers could be useful for purulent finger osteomyelitis with bone and joint destruction.

PATIENTS AND METHODS

Seven patients with finger osteomyelitis with bone and joint destruction were treated using vancomycin (VCM)-impregnated cement spacers. During the first surgery, a cement spacer was placed in the space created after debridement, maintaining finger length. Intraoperative specimens were tested for bacterial growth. Systemic antibiotic treatment was administered. A second surgery was performed 6-8 weeks after the first. After spacer removal, reconstruction surgeries were performed: arthrodesis using the Masquelet technique (n = 5), vascularized bone grafting (n = 1), and silicone implant arthroplasty (n = 1). We assessed the pathogenic bacteria, duration of antibiotic treatment, infection control, time to bone union, pain on visual analogue scale (VAS) (0 - 100), total active motion (TAM) of the affected fingers, and grip strength.

RESULTS

The pathogenic bacteria were methicillin-sensitive Staphylococcus aureus, methicillin-resistant Staphylococcus aureus, and unknown in 3, 3, and 1 patients, respectively. Mean duration of antibiotic treatment was 6.4 weeks. In all patients, infection resolved without recurrence. One patient underwent joint arthroplasty; otherwise, bone union was achieved in 6 patients. Mean VAS score for pain was 0.9. Mean TAM was 147° for the index and middle fingers and 50° for the thumb. Mean grip strength was 86.4% of that of the unaffected side.

CONCLUSION

VCM-impregnated cement spacers could be useful for finger osteomyelitis, facilitating effective infection control and the maintenance of finger length, even in severe conditions.

New classification for septic arthritis of the hand

The severity of septic arthritis of the hand and the prospects for restoration of joint function are determined by a complex of factors. Among them, the leading role belongs to local changes in tissue structures. This includes the destruction of articular cartilage and bone tissue with the development of osteomyelitis, the involvement of paraarticular soft tissues in the purulent process, and the destruction of the flexor/extensor tendons of the fingers. The currently missing specialized classification of septic arthritis could help in systematizing the diseases, determining treatment tactics, and predicting the results of treatment. The classification of septic arthritis of the hand proposed for discussion is based on the following principle: Joint−Wound−Tendon (J_xW_xT_x); J_x characterizes damage to the osteochondral structures of the joint, W_x is the presence of paraarticular purulent wounds or fistulas, and T_x is destruction of the flexor/extensor tendons of the finger. The classification of the diagnosis makes it possible to assess the nature and severity of damage to the structures of the joint and may also be useful when comparing the results of treatment of septic arthritis of the hand.