Flexor sheath infections

Question 1

What is flexor sheath infections in the hand ?

Answer 1

Infection of the synovial sheath that surrounds the flexor tendon

Question 2

What is the mechanism?

Answer 2

Penetrating trauma to tendons

direct spread from felon, septic joint and deep space infection

Question 3

what are the organisms typically involved?

Answer 3

Staoh aureus

Gram negative and anerobic bacteria

Question 4

What conditions are commonly associated ?

Answer 4

IV drug sbusers- significant risk of MRSA
diabetes
farmyard injuries
animal bites

Question 5

What may the infection develop into?

Answer 5

A horse shoe abscess as conditions of radial flexor tendon sheath ( thumb) l and ulna flexor tendon sheaths ( little finer) at the wrist

Question 6

Where do the flexor synovial sheaths extend from ?

Answer 6

DIPJ to midplam in index, middle and ring fingers
DIPJ to wrist in little finger
IPJ to wirst in thumb

Question 7

What are the presentation ?

Answer 7

Pain which developed over the last 24-48 hours

usually located to palmar aspect of one digit

Question 8

What clinical signs maybe present? How are they associated with?

Answer 8

KANAVEL signs 4 in total

FUSIFORM SWELLING OF DIGIT
FLEXED POSITION of involved digit
TENDERNESS on PALPATION over TENDON SHEATH
MARKED PAIN with PASSIVE EXTENSION

Question 9

What is the tx ?

Answer 9

Non op- for early intervention 1-2 kanavel signs= splinting, elevation and iv antibiotics

Mainly surgical draininage

Question 10

What is problem with pyogenic flexor sheath infections?

Answer 10

The incrase in pressure leads to obstruction of arterial blood flow to the flexor tendon thru vincula system-> necrosis and rupture

Question 11

How do you preform surgery?

Answer 11

Aspirate sheath first to obtain sample between palmodigital crease and dipj - use 20 gauge needle under a1 pulley

2 incisions- one prox to a1 pullet at mcpj- transverse incision
2nd incision is proximal to DIPJ crease. tendon sheath exposed. NV bundles identifed, protected. a catheter ( no5 paed feeding tube) is places down the sheath and irrigated prox to distal to avoid infection into palm!!irrigate until fluid is clear.if required can do a continous drip of saline at 1 drop per second fr 24-48 hours. catheter is removed and exercise started. wick gauze into wounds to prevent closure

Question 12

What is your post op tx?

Answer 12

iv antibiotics
analgesia
forst change dressing between 8-12hours
soaks in dilute povidone -idoine x3 per day
rpt in 48hours if Kanavel’s signs not resolving