Review Article

Flexor Tendon Sheath Infections of the Hand

Abstract
Reid W. Draeger, MD Donald K. Bynum, Jr, MD

Flexor tendon sheath infections of the hand must be diagnosed and treated expeditiously to avoid poor clinical outcomes. Knowledge of the sheaths anatomy is essential for diagnosis and to help to guide treatment. The Kanavel cardinal signs are useful for differentiating conditions with similar presentations. Management of all but the earliest cases of pyogenic exor tenosynovitis consists of intravenous antibiotics and surgical drainage of the sheath with open or closed irrigation. Closed irrigation may be continued postoperatively. Experimental data from an animal study have shown that local administration of antibiotics and/or corticosteroids can help lessen morbidity from the infection; however, additional research is required. Despite aggressive and prompt antibiotic therapy and surgical intervention, even otherwise healthy patients can expect some residual digital stiffness following exor tendon sheath infection. Patients with medical comorbidities or those who present late with advanced infection can expect poorer outcomes, including severe digital stiffness or amputation.

From the Department of Orthopaedics, University of North Carolina School of Medicine, Chapel Hill, NC. Dr. Draeger or an immediate family member has stock or stock options held in GlaxoSmithKline. Neither Dr. Bynum nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article. J Am Acad Orthop Surg 2012;20: 373-382 http://dx.doi.org/10.5435/ JAAOS-20-06-373 Copyright 2012 by the American Academy of Orthopaedic Surgeons.

lexor tendon sheath infections of the hand can be devastating. Prior to the advent of antibiotic therapy, such infections led to morbidity, including loss of limb or life. Good functional results have been achieved with closed tendon sheath irrigation and postoperative treatment using continuous closed irrigation systems.1-4 However, nearly a century after Kanavels seminal work on the subject,5 patients with pyogenic flexor tenosynovitis (PFT) remain at risk of great morbidity (eg, digit stiffness, amputation) despite modern antibiotic and surgical treatment.

Anatomy
Accurate diagnosis and management, particularly surgical management, of flexor tendon sheath infections requires an understanding of the anat-

omy involved. Several variations of flexor tendon sheath anatomy have been reported6 (Figure 1). Distal termination of the sheath of each finger is at the bony insertion of the flexor digitorum profundus (FDP) tendon. In the thumb, the sheath terminates at the flexor pollicis longus (FPL) tendon. Typically, the proximal extent of the sheaths of the index, middle, and ring fingers lies just proximal to the A1 pulley.6,7 The FPL sheath extends proximally as the radial bursa to approximately 2.5 cm proximal to the wrist flexion crease.8 Phillips et al9 and Scheldrup6 reported that the flexor tendon sheath of the little finger communicated proximally with the ulnar bursa in 32% and 80% of patients in their series, respectively. In the palm, the ulnar bursa surrounds the FDP and flexor digitorum

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Figure 1

Illustration demonstrating the anatomic variations of the exor tendon sheath and bursa patterns of the hand as well as their relative frequency. (Reproduced with permission from Doyle JR, Botte MJ: Hand, in Doyle JR, Botte MJ, eds: Surgical Anatomy of the Hand and Upper Extremity. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, p 605.)

superficialis tendons of the index, long, and ring fingers, although the bursa is not commonly contiguous with the sheaths of these digits distally.6,7 Proximally, the ulnar bursa extends to the same level as and is contiguous with the radial bursa in approximately 80% of persons.6,7 This explains formation of a horseshoe abscess in which an infection in the small finger tracks into the palm and out to the thumb, or vice versa. The digital flexor tendon sheath is composed of retinacular (pulley) and synovial (membranous) tissue. The pulley system is composed of transverse (palmar aponeurosis pulley), annular (A1-A5), and cruciform or

cruciate (C1-C3) pulleys10,11 (Figure 2). A2 and A4 are the broadest pulleys; during surgical drainage in patients with PFT, sectioning of these pulleys should be avoided to minimize the risk of tendon bowstringing. The narrower annular and the cruciform pulleys accommodate finger flexion without buckling of the pulley system or impingement of the flexor tendons.7 The thumb has two annular pulleys, A1 and A2, with a broad, thick oblique pulley between them (Figure 3). When draining infections of the flexor tendon sheath of the thumb, sectioning of the oblique pulley must be avoided to prevent iatrogenic loss

of interphalangeal joint extension caused by bowstringing.7 The synovial portion of the sheath is a double-walled tube that is considered a closed anatomic space. The tube is composed of an inner visceral layer, or epitenon, and an outer parietal layer, which is reinforced by thickening of the retinacular pulleys.7,12 The synovial portions of the sheath are visible in the spaces between the pulleys. The visceral and parietal layers are contiguous at the proximal cul-de-sac (ie, the proximal origin of the sheath), the vinculae, and the distal extension of the sheath.12 A synovial space is located between the two layers and becomes

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Figure 2

Figure 3

Illustrations of the pulley system of the nger. A, The palmar aponeurosis pulley (PA), A2, and A4 overlie the metacarpal, proximal phalanx, and middle phalanx, respectively. The narrower A1 and A3 pulleys are located over the metacarpophalangeal and proximal interphalangeal joints, respectively. The narrowest of the annular pulleys, A5, extends to the distal interphalangeal joint. The cruciform pulleys, C1, C2, and C3, are located at the distal end of the A2 pulley, between A3 and A4, and at the distal end (or sometimes as an extension) of the A4 pulley, respectively. B, The two brous layers of A2 are demonstrated, with the annular bers of the pulley overlaid by oblique bers that coalesce at the distal end of the pulley to form C1. (Redrawn with permission from Doyle JR: Anatomy of the exor tendon sheath and pulley system: A current review. J Hand Surg Am 1989;14[2]:349-351.)

Illustration of the thumb pulley system. The annular pulleys of the thumb, A1 and A2, overlay the metacarpophalangeal and interphalangeal joints, respectively. The oblique pulley overlies the proximal phalanx and runs obliquely from its proximal origin on the ulnar aspect of the proximal phalanx to a distal insertion on the radial aspect of the proximal phalanx. (Redrawn with permission from Zissimos AG, Szabo RM, Yinger KE, Sharkey NA: Biomechanics of the thumb exor pulley system. J Hand Surg Am 1994;19[3]:475-479.)

distended under pressure with an infection. Pressure in the sheath can result in the spread of infection into neighboring bursae and fascial spaces within the hand and may extend into the forearm through the Parona space (ie, the potential space between the flexor tendons and the pronator quadratus). The nutrition that the flexor tendons rely on is provided via the extrinsic blood supply through the vinculae and diffusion through the synovial fluid. PFT has been found to markedly increase pressure in the sheath, sometimes exceeding 30 mm Hg, and may lead to tendon necrosis via inhibition of extrinsic blood
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flow.13 Consequently, prompt drainage and decompression of the sheath are critical.

Infectious Epidemiology
Although hematogenous seeding of the flexor tendon sheath is possible, PFT is typically caused by a puncture wound.1,14,15 Given this mechanism of injury, skin flora, most commonly Staphylococcus aureus, was found in 40% to 75% of positive cultures in several series.1-3,14,16-19 Methicillinresistant S aureus (MRSA) has been found in up to 29% of cases in several series and must be considered when de-

termining appropriate preculture antibiotic treatment.19-21 Other commonly isolated bacteria include S epidermidis, -hemolytic Streptococcus species, and Pseudomona aeruginosa.20,22 Infections with mixed flora or Gram-negative rods are also common in immunocompromised patients; therefore, presumptive antibiotic coverage should be broad. In one recent series, mixed flora infections were found in 36 of 61 patients (59%), with 26% of cultures demonstrating mixtures of anaerobic and aerobic organisms.3 Rarely, PFT can be caused by Eikenella corrodens from a human bite or Pasteurella multocida from an animal bite.20 Other rare causes of PFT include

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Figure 4

A, Clinical photograph of the right hand demonstrating pyogenic exor tenosynovitis (PFT) of the index nger. Note the fusiform swelling and partially exed posture of the digit. B, Clinical photograph of the left hand of a patient with advanced PFT demonstrating subcutaneous purulence and local ischemia in addition to fusiform digital swelling. (Courtesy of Robert Strauch, MD, New York, NY.)

Listeria monocytogenes, which has been identified in farm workers,23 Clostridium difficile, which was found in patients with a previously treated infection elsewhere,24 and Neisseria gonorrhoeae, which was reported in sexually active adolescents in the setting of disseminated gonococcal infection.25 Culture-negative cases of PFT are also common and have been reported in 20% to 63% of cases in several studies.1-3,14,16-19 Cultures may be negative as a result of presumptive antibiotic treatment or a vigorous immune response. Presumptive treatment should include broadspectrum antibiotics to treat both Gram-positive cocci and Gramnegative rods. Institutional and local antibiotic resistance patterns of bacteria should guide treatment. Routine presumptive coverage at our institution includes an intravenous (IV) antibiotic that covers MRSA, given its high prevalence as a causative organism of PFT. In patients with indolent clinical courses, mycobacterial infection

should be suspected. Mycobacterium marinum should be considered in the patient with a puncture wound sustained in a marine setting. M kansasii is the second most common mycobacterial isolate in persons with chronic atypical mycobacterial synovitis.26 Bacteria may take 6 weeks to grow in culture, delaying definitive diagnosis; therefore, presumptive antibiotic treatment is needed when mycobacterial infection is suspected.27 Intraoperatively, exuberant synovitis is encountered and may require complete synovectomy to dbride the infected tissue.27

Diagnosis
Prompt diagnosis of PFT is essential to institute effective treatment. In our experience, patients with PFT have a history of penetrating trauma to the hand 2 to 5 days before presentation, but immunocompromised patients may present even later. Close examination of the hand may reveal cuts, scratches, or puncture

wounds. The presence and timing of seeding trauma can be helpful in guiding management of the infection. Diagnosis of PFT is primarily clinical. Radiographs of the hand are obtained to rule out bony trauma or the presence of a retained foreign body. Typically, MRI and ultrasonography are unnecessary for diagnosis. Laboratory tests such as erythrocyte sedimentation rate and C-reactive protein level are nonspecific and unhelpful for initial diagnosis, but they may be useful if monitored over time to gauge response to treatment. Kanavel5 described four cardinal signs that characterize infection of the flexor tendon sheath. These signs include symmetric swelling of the entire digit, exquisite tenderness along the course of the tendon sheath, a digit with a semiflexed posture, and pain with attempted passive extension of the digit. These signs have been widely used as diagnostic criteria for PFT (Figure 4). Clinical experience has shown that these clinical signs are useful for diagnosis of PFT; however, no studies have validated their sensitivity and specificity. In a study of 75 patients with PFT, Pang et al17 found that fusiform swelling was most often present (97% of patients), followed by pain on passive extension (72%), semiflexed digit posture (69%), and tenderness along the flexor tendon sheath (64%). In a retrospective review of 41 patients with PFT, Dailiana et al19 reported that all patients had tenderness along the flexor tendon sheath and pain with passive extension. However, only 22 of 41 patients (54%) exhibited all four Kanavel cardinal signs. Neviaser and Gunther28 reported that the most reliable Kanavel sign is pain on passive extension of the digit. They also found that the inability to flex the finger to touch the palm was another clinical sign of PFT. We agree with others who have suggested that tenderness along the

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flexor tendon sheath that may extend into the palm is a valuable clinical sign that can be used to differentiate PFT from other conditions (eg, herpetic whitlow, septic arthritis).14,15,26 These conditions may clinically resemble infections of the flexor tendon sheath in the hand; however, patients with these conditions often lack Kanavel signs. A thorough history is also important for diagnosis of PFT. Patients with medical comorbidities such as diabetes mellitus or IV drug use, or those with compromised immune systems, may not exhibit Kanavel signs as dramatically as those with healthy immune systems.

Figure 5

Figure 6

Differential Diagnosis Herpetic Whitlow

Herpetic whitlow is a rare clinical entity that represents a cutaneous infection with herpes simplex virus and is most often found in medical and dental professionals. Patients report pain in the affected digit, typically at the distal tip of the finger, and often have painful, clear, fluid-filled vesicles, which may coalesce into painful bullae (Figure 5). Acyclovir or similar antiviral agents can be used to manage the infection; surgical drainage of the vesicles should be avoided because it can lead to systemic dissemination of a localized infection or bacterial superinfection of the site.15

Clinical photograph of a nger demonstrating herpetic whitlow. Note the coalescence of the uidlled vesicles. (Reproduced with permission from Stern PJ: Selected acute infections. Instr Course Lect 1990;39:539-546.)

Clinical photograph of the left hand demonstrating a felon of the index nger. Note that the tense swelling of the pulp does not extend more proximally along the tendon sheath. (Reproduced with permission from Stern PJ: Selected acute infections. Instr Course Lect 1990;39: 539-546.)

course of the tendon sheath associated with PFT.

Crystal-induced Arthritides and Tenosynovitis

Gout and pseudogout flares of the hand joints can present as localized pain at the involved joint or swelling about the length of the affected digit. Clinically, these patients lack pain along the course of the flexor tendon sheath, often do not have the pain with passive stretch to the extent associated with PFT, and typically lack a partially flexed posture in the affected digit. In general, these patients experience less severe pain in the involved joints with active and passive range of motion (ROM) than do patients with pyarthrosis. Patients with gouty tenosynovitis may have a clinical presentation similar to that of PFT and may exhibit any of the four Kanavel signs, although patients with gouty tenosynovitis typically exhibit fewer dramatic signs than do patients with PFT.29,30 Diagnosis of gout or

pseudogout can be confirmed via aspiration of the involved joint or tendon sheath, followed by crystal analysis. The presence of tophaceous deposits provides strong proof of gout. Gout and infection may be concurrent; therefore, the decision to proceed with antibiotic or surgical management should be based primarily on clinical suspicion for infection as well as initial Gram stain and culture results.

Other Hand Infections

Paronychia, felons, cellulitis, and deep space infections of the hand can be confused with infection of the flexor tendon sheath, especially if the infection is severe. Patients with paronychia experience the most dramatic pain, swelling, and erythema adjacent to the nail fold, whereas patients with felons experience the most severe pain at the distal pulp of the finger (Figure 6). Palpable fluctuance or tense localized swelling can

Septic Arthritis
Septic arthritis of an interphalangeal or metacarpophalangeal joint presents as localized pain, swelling, and erythema about the infected joint. Active or passive motion at the joint elicits exquisite pain. The joint may be held in partial flexion in an attempt to lessen painful tension on the joint capsule. Patients with septic arthritis lack the fusiform digital swelling and pain along the entire
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often be appreciated with both of these clinical entities. The patient with cellulitis can be more easily assessed for PFT following elevation of the affected hand and administration of antibiotics to decrease the initial swelling associated with cellulitis. Deep infections of the hand often result in more diffuse swelling than that associated with PFT. Given the close proximity of the spaces in the hand and the communication between them, an infection in one area, especially when severe and pyogenic, may spread to adjacent spaces. Through this mechanism, PFT may be associated with other hand infections, including septic arthritis, paronychia, felon, and deep space infection.

Nonsurgical Management
Management of PFT has evolved to include prompt administration of IV antibiotics, and several surgical methods have been developed to thoroughly decompress and irrigate the sheath. Nonsurgical treatment may be appropriate for patients with PFT who present early, typically within 48 hours following penetrating trauma to the hand. In a small case series, Neviaser and Gunther28 reported successful nonsurgical management of PFT with IV antibiotics, splinting, and elevation in four patients. Patients with early PFT may have less dramatic positive Kanavel signs than those who present later. During nonsurgical treatment, the affected hand should be examined regularly. If treatment is successful, improvement of clinical symptoms should be seen within 48 hours.28 If no improvement or worsening of symptoms are seen within 12 to 24 hours after initiating nonsurgical treatment, the patient should undergo surgical irrigation and dbridement.

Regardless whether surgical intervention is needed, IV antibiotics play a key role in treatment. Consultation with an infectious disease specialist can yield valuable information regarding local antibiotic resistance patterns, antibiotic choices, and duration of treatment. We do not routinely consult an infectious disease specialist for management of uncomplicated cases of PFT in an otherwise healthy patient. However, consultation can be helpful in the setting of antibiotic-resistant organisms or immunocompromised hosts. Prior to obtaining culture results, antibiotic selection should include presumptive coverage against common Gram-positive organisms, including Staphylococcus (especially MRSA) and Streptococcus species.19 Presumptive antibiotics should also cover Gram-negative rods and anaerobes (including Clostridium species), especially in immunocompromised patients.19 These patients may require additional antibiotics for presumptive coverage of other bacteria. Given the prevalence of MRSA in our patient population, presumptive antibiotic coverage in otherwise healthy patients includes 1 g of vancomycin administered intravenously every 12 hours and 3.375 g of piperacillin/tazobactam administered intravenously every 6 hours to cover possible Gram-negative rods in mixed-flora infections. In immunocompromised hosts or in patients with particularly severe PFT with subcutaneous purulence, presumptive treatment with antibiotics to cover both Gram-positive and Gramnegative bacteria is especially important because of the high incidence of mixed-flora infections in this population. Once the results of the cultures are available, antibiotic regimens should be tailored to cover the etiologic organisms identified. Duration of antibiotic treatment depends on the patients clinical re-

sponse. IV antibiotics are continued until the transition can be made to specific oral medication based on culture results. In recalcitrant cases of PFT, IV antibiotics are continued and, occasionally, repeat irrigation and dbridement is necessary. At the time of discharge, we prescribe an additional 10-day course of oral antibiotics (eg, cephalexin 500 mg or dicloxacillin 500 mg every 6 hours for oxacillin-sensitive S aureus, clindamycin 600 mg every 6 hours and trimethoprim/sulfamethoxazole DS 160/800 mg twice daily for MRSA). For culture-negative infection, broadspectrum IV antibiotics can be discontinued with transition to multiple broad-spectrum oral antibiotics (especially those that cover MRSA). Discharge is based on improvement of symptoms on clinical examination.

Surgical Management Open Irrigation and Dbridement

Open irrigation and dbridement procedures were originally described for surgical management of PFT.5 Both midaxial and volar zigzag incisions can be used to expose and open the entire sheath for complete drainage and irrigation5,31 (Figure 7). Some believe that volar zigzag incisions should be avoided, given the potential risk of wound breakdown over the flexor sheath and tendon.32 Open irrigation and dbridement remains the treatment of choice for the most advanced cases of PFT and in cases of atypical or chronic tenosynovial infections in which complete tenosynovectomy may be necessary for eradication of infection.1,17,28,31 We prefer to close all wounds with minimal tension on the skin, and we leave space between each stitch to allow for continued drainage and to encourage a tension-free healing environment for the tissue.

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Closed Tendon Sheath Irrigation

Although initially described by Dickson-Wright,33 Neviaser1 wrote extensively on closed tendon sheath irrigation for management of PFT. A proximal zigzag incision is made over the metacarpal neck. The tendon sheath is incised transversely at the proximal edge of the A1 pulley, and synovial fluid is collected for culture. Under direct visualization, a 16- or 18-gauge angiocatheter is then threaded 1.5 to 2 cm into the flexor tendon sheath. Next, a distal midaxial incision is made dorsal to the neurovascular bundle at the level of the distal interphalangeal joint on the ulnar aspect of the finger or the radial aspect of the thumb. The distal edge of the sheath is exposed and resected distal to the distal-most pulley. A Penrose drain is threaded into the tendon sheath beneath the A4 pulley to allow for drainage of irrigant (Figure 8). The sheath is flushed gently in the operating room, and intermittent bedside irrigation can be continued postoperatively, if desired. For PFT infections of the thumb, the proximal catheter is placed into the FPL sheath just distal to the carpal canal. For the small finger, if the ulnar bursa is involved, a second catheter is placed distal to proximal from the A1 pulley, with another Penrose drain placed at the wrist. Neviaser1 reported excellent results with this technique, including full active ROM at 1 week postoperatively in 18 of 20 patients. Gutowski et al31 retrospectively compared closed-catheter irrigation with open irrigation and dbridement for management of PFT. The authors found no significant differences between the groups in terms of early postoperative outcomes, including resolution of infection, need for additional surgery, and length of hospital stay. They found a trend toJune 2012, Vol 20, No 6

Figure 7

Figure 8

Illustration demonstrating placement of a midaxial incision for open drainage of pyogenic exor tenosynovitis. This approach may be combined with a transverse incision at the level of the distal palmar crease to gain proximal access to the tendon sheath for drainage or to obtain a culture. (Redrawn with permission from Stevanovic MV, Sharpe F: Acute infections, in Wolfe SW, Hotchkiss RN, Pedersen WC, Kozin SH: Greens Operative Hand Surgery, ed 6. Philadelphia, PA, Churchill Livingstone, 2011, vol 1, pp 41-84.)

Illustration demonstrating Neviasers technique for closed tendon sheath irrigation. The technique consists of a proximal zigzag incision for exposure of the tendon sheath, introduction of irrigant into the sheath through a catheter, and a distal counterincision into which a Penrose drain is placed to allow irrigant drainage. (Redrawn with permission from Stevanovic MV, Sharpe F: Acute infections, in Wolfe SW, Hotchkiss RN, Pedersen WC, Kozin SH: Greens Operative Hand Surgery, ed 6. Philadelphia, PA, Churchill Livingstone, 2011, vol 1, pp 41-84.)

ward more surgical complications in the open drainage group, but this trend was not statistically significant. Although no long-term results were reported due to poor follow-up, the study supports the possible superiority of closed irrigation over open irrigation and dbridement for management of PFT. The best irrigant for closed irrigation is debated. Many believe that antibiotic irrigants are no better at eradicating infection than is lavage with normal saline alone.1,2,31 Others argue that local antibiotics may elicit a local synovitis reaction and that effective

selection of antibiotics is difficult in the absence of culture data.1,2,31,32 In general, good results have been reported with the use of local antibiotics and bactericidal irrigants.14,33-35 However, other irrigants, such as hydrogen peroxide, may cause cell death in native tissue and should be avoided.1,31 Although more research is required to define concentrations toxic to local tissues, locally administered antibiotics may provide local control of infection without risk of systemic toxicity.

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Figure 9

Figure 10

emphasize correct placement of the catheter lateral to the flexor tendons to permit easier passage of the catheter, avoid entrapment at the Camper chiasm, and minimize trauma to the sheath, tendons, and vinculae (Figure 10).

Postoperative Irrigation
Duration of postoperative irrigation for management of flexor tendon sheath infection varies in the literature. In two series in which thorough intraoperative tendon sheath irrigation was performed in patients with hand infections,2,36 the duration of indwelling catheter treatment was shorter than that of other trials,16 suggesting that thorough intraoperative irrigation may be the most important surgical step for management of these infections. Although no study has examined the effects of leaving an indwelling catheter in the tendon sheath, the practice itself may result in complications. Catheters may increase digital stiffness by decreasing the patients ability to participate in therapy or may cause a foreign body reaction if left in place too long. The surgeon must weigh these risks with the potential benefits of postoperative catheter irrigation. Lille et al3 retrospectively compared the results of intraoperative closed tendon sheath irrigation alone with those of intraoperative and postoperative closed tendon sheath irrigation. They found no significant differences in terms of mean length of hospital stay, follow-up complication rates, or postoperative ROM, suggesting that postoperative intermittent or continuous irrigation is not required.

Illustration demonstrating the nested catheter method of continuous irrigation described by Harris and Nanchahal2 and Nemoto et al.16 An infant feeding tube is passed into the sheath in a distalto-proximal direction and is threaded into a pediatric feeding tube passed into the sheath proximal to distal. (Redrawn with permission from Harris PA, Nanchahal J: Closed continuous irrigation in the treatment of hand infections. J Hand Surg Br 1999;24[3]:328-333.)

Cross-sectional illustration of a digit demonstrating placement of the irrigation catheter (arrow) lateral to the exor tendons to avoid entrapment in the Camper chiasm. (Adapted with permission from Gaston RG, Greenberg JA: Use of continuous marcaine irrigation in the management of suppurative exor tenosynovitis. Tech Hand Up Extrem Surg 2009;13[4]:182-186.)

Continuous Closed Irrigation

Use of a continuous closed irrigation system is a popular option for management of PFT. Advantages of these systems include the patients ability to participate in hand therapy with the system in place and avoidance of pain caused by high pressures associated with intermittent closed irrigation.2,4,14 Single catheter and nested catheter irrigation systems with catheters threaded through the tendon sheath have been described.2,4,16,36 In nested catheter systems, an infant feeding tube (No. 4 French) serves as an inflow catheter and is threaded in a distal-to-proximal direction within

a slightly larger pediatric feeding tube (No. 8 French) threaded proximal to distal; the larger tube serves as an outflow catheter for irrigant2,16 (Figure 9). This system helps to minimize soft-tissue blockage of the catheters and allows them to telescope within each other during ROM exercises. Duration of treatment with a nested catheter system ranges from 2 days to 3 weeks and is reported to produce good results, with uniform eradication of infection.2,16 Recently, Gaston and Greenberg36 described another irrigation system in which there is a continuous infusion of a local anesthetic (eg, bupivacaine) via an external pump. A catheter is passed distal to proximal through the sheath to provide continuous anesthetic irrigation. This system reportedly provides less painful continuous irrigation and allows for more active participation in hand therapy, with shorter periods of continuous irrigation (2 days) and a trend toward shorter hospital stays (average, 2.8 days).36 The authors

Future Directions
In a recent animal study, Draeger et al37 reported promising results with local injection of antibiotics

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into the tendon sheath and the addition of locally administered corticosteroids to the PFT treatment regimen. However, clinical studies are required before these modalities can be implemented in clinical practice. Just as corticosteroids have been shown to decrease morbidity in other closed-space infections (eg, septic arthritis,38 septic nephritis39) by dampening the hosts inflammatory response, Draeger et al37 found that corticosteroids also decreased digit stiffness associated with PFT. This is compelling preclinical evidence for the efficacy of corticosteroids as an adjunctive treatment for PFT.

Complications
The primary complication associated with PFT is stiffness secondary to flexor tendon adhesions, joint capsular thickening, or destruction of the sheath and pulley system as a result of infection or iatrogenic injury.32 Other complications include tendon rupture, spread of infection to surrounding structures, or loss of the skin over infected tissue, which may necessitate flap coverage.32 Most PFT infections can be managed without amputation; however, patients with osteomyelitis, soft-tissue loss, or stiffness may require amputation of the affected digit. In several series, 10% to 25% of patients with PFT failed to obtain full ROM despite treatment.1-3,14,36 Full active ROM exercises should be initiated immediately postoperatively to decrease stiffness. In patients with hand stiffness despite physical therapy, flexor tenolysis can be performed to restore some active ROM only after the tissue bed has reached equilibrium (ie, local inflammation is absent) and passive motion exceeds active motion.15 Despite aggressive management of PFT, two studies reported amputaJune 2012, Vol 20, No 6

tion incidence of 17%17 and 29%.18 Maloon et al18 found that amputation was often necessary in patients with diabetes and of delayed presentation. Pang et al17 identified five risk factors associated with an increased risk of amputation in patients with PFT, including (1) age >43 years, (2) diabetes mellitus, peripheral vascular disease, or renal failure, (3) presence of subcutaneous purulence, (4) signs of digital ischemia at presentation, and (5) the presence of multiple causative organisms. The authors proposed a classification system based on increasingly severe clinical presentation: Kanavel cardinal signs; subcutaneous purulence; and digital ischemia, which was found to correlate with worse outcomes in patients with PFT. In 21 patients with Kanavel signs alone, no amputations were required, and the average recovery of total active motion in the digits was 80%.17 In 37 patients with Kanavel signs and subcutaneous purulence without digital ischemia, the amputation rate was 8%, and the return of total active motion in the remaining digits was 72%. The amputation rate in 17 patients with all three of the classification criteria was 59%, and the return of total active motion in the remaining digits was 49%.

PFT from other conditions. Presumptive antibiotic therapy should be broad and include coverage of S aureus, Streptococcus species, and Gram-negative organisms until culture results are available to allow tailoring of antibiotic therapy to the causative organism. Management of PFT should include thorough irrigation of the tendon sheath via closed methods in most cases or open methods in advanced cases with digital ischemia. Even with prompt treatment, patients with minimal comorbidities can develop permanent finger stiffness. Hand therapy is often required to maximize digital motion. Poor outcomes, including amputation of the affected digit, may occur despite aggressive dbridement and antibiotic therapy in patients with comorbidities (eg, diabetes mellitus) and those who present late and have digital ischemia or subcutaneous purulence. Prospective trials are needed to determine the efficacy of adjunctive corticosteroids or local antibiotic injection.

References
Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, reference 38 is a level I study. Reference 17 is a level II study. References 3, 19, and 31 are level III studies. References 1, 2, 4, 13, 14, 16, 18, 21, 23-25, 27, 29, 30, 34, and 36 are level IV studies. References 33 and 35 are level V expert opinion. References printed in bold type are those published within the past 5 years.
1. Neviaser RJ: Closed tendon sheath irrigation for pyogenic flexor tenosynovitis. J Hand Surg Am 1978; 3(5):462-466. Harris PA, Nanchahal J: Closed continuous irrigation in the treatment of hand infections. J Hand Surg Br 1999; 24(3):328-333. Lille S, Hayakawa T, Neumeister MW,

Summary
Flexor tendon sheath infections of the hand continue to present clinical challenges despite advances in antibiotic therapy and surgical management. Prompt diagnosis and management is paramount to avoid digit and tendon ischemia from increased pressure in the sheath. Kanavel cardinal signs are useful for diagnosis, and tenderness along the flexor tendon sheath (often extending into the palm) and pain with passive extension of the digit are signs that are especially helpful in differentiating

2.

3.

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Brown RE, Zook EG, Murray K: Continuous postoperative catheter irrigation is not necessary for the treatment of suppurative flexor tenosynovitis. J Hand Surg Br 2000; 25(3):304-307. 4. Gosain AK, Markison RE: Catheter irrigation for treatment of pyogenic closed space infections of the hand. Br J Plast Surg 1991;44(4):270-273. Kanavel AB: The symptoms, signs, and diagnosis of tenosynovitis and major fascial-space abscesses, in Kanavel AB, ed: Infections of the Hand, ed 6. Philadelphia, PA, Lea and Febiger, 1933, pp 364-395. Scheldrup EW: Tendon sheath patterns in the hand: An anatomical study based on 367 hand dissections. Surg Gynecol Obstet 1951;93(1):16-22. Doyle JR: Hand, in Doyle JR, Botte MJ, eds: Surgical Anatomy of the Hand and Upper Extremity, ed 1. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 532-666. Doyle JR, Blythe WF: Anatomy of the flexor tendon sheath and pulleys of the thumb. J Hand Surg Am 1977;2(2):149151. 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Journal of the American Academy of Orthopaedic Surgeons