This document discusses flexor sheath infections of the fingers. It notes that these infections usually result from penetrating trauma and are more common at finger joint flexion creases. Left untreated, the infections can destroy the tendon gliding mechanism, lead to adhesions, and cause tendon necrosis. Poor prognosis is associated with factors like age over 43, diabetes, or presenting with a high stage of infection involving subcutaneous purulence or digital ischemia. Treatment involves antibiotics and surgical drainage or irrigation of the flexor sheath depending on the infection stage. Chronic tenosynovitis can also rarely occur from puncture wounds in aquatic environments.

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2. ANATOMY
membranous + retinacular portions
Extend from the mid-palmar crease
to the DIPJ
small finger continuous with the
Ulnar Bursa,
thumb is continuous with the
Radial Bursa
Radial & Ulnar bursae extend
proximal to the TCL and connect
with the Parona space
(FDP & PQ muscle)

3. FLEXOR SHEATH INFECTION
 F.S. infection  penetrating trauma
 More likely at joint flexion creases
 small amount of subcutaneous tissue
 Felons
 Usual agent: S. Aureus
 Most commonly affected : (Ring,
Middle& index fingers)

4. FLEXOR SHEATH INFECTION
 Purulence  destroys gliding  adhesions  loss of function
 destroys the blood supply producing tendon necrosis

5. P ROGNOS I S
Among 75 patients with infectious tenosynovitis involving
the upper extremity, risk factors associated with poor
outcome included [13]:
– Age >43
– Presence of diabetes mellitus, peripheral vascular disease,
or renal failure
– Subcutaneous purulence
– Digital ischemia
– Polymicrobial infection
• Patients who presented with stage 3 infection had the
worst prognosis (amputation rate 59 percent

6. DI AGNOS I S
 Tenderness over & limited to the flexor sheath
 Symmetrical enlargement of the digit (“fusiform”)
 Severe pain on passive extension of the finger (> proximally)
 Flexed posture of the involved digit
Kanavel’s cardinal signs

7. TENOSYNOVITIS OR NOT ?

8. T R E ATME N T
Stage 1:
 < 48 hrs  may initially with IV Abx, splinting
& elevation
Failure to respond within 24 hrs. drainage
vancomycin + ciprofloxacin +/- ceftriaxone
water-related injuries should include activity
against Pseudomonas aeruginosa.
 >48 hrs  SURGICAL EMERGENCY
 Requires prompt surgical drainage
 Delays may result in tendon
&/or skin necrosis

9. 1- Open drainage:
T R E ATME N T
 Decompression of the entire tendon
sheath via mid-axial & palmar incisions
 Wounds are left open to drain & heal
secondarily
 Rehab is prolonged; permanent finger
stiffness not infrequent
 Most useful for advanced cases where
resection of necrotic tendon is required

10. T R E ATME N T
2 - Closed tendon-sheath irrigation:
 2 incisions made
 Proximal palm: proximal to the A1 pulley
 Distal mid-axial: distal to the A4 pulley
 Long catheter (16 - 18g) in the proximal sheath with
a drain left in the distal incision
 then close, and irrigate for 48 - 72 hrs.
 NS or Abx solution (continuous/q2h flush)
 Marcaine alleviates pain of irrigation
 Modification : multiple transverse incisions of
cruciate pulleys with insertion of silastic drains
adequate drainage / heal quickly / Do not interfere with rehab

11. T R E ATME N T
• Stage 1  tendon sheath irrigation and
drainage, with or without debridement.
• Stage 2 or 3 surgical debridement of the
tendon sheaths and surrounding necrotic
tissue
• Amputation may be necessary in severe cases

12. Chronic Tenosynovitis
 Unusual
 Chronic swelling of the flexor sheath
 No disabling pain or loss of function
 most frequently caused by mycobacteria
 usually the result of a puncture wound in an aquatic environment
 M. Kansasii or M. Marinarum
 Dx: AFB stains & culture of synovium
 Tx: tenosynovectomy + antituberculous drugs (6 - 24 mo)

13. Thank you..