Treatment of Pyogenic Flexor Tenosynovitis in the Emergency Department Setting With WALANT Technique

Background The standard of care for treatment of pyogenic flexor tenosynovitis (PFT) involves antibiotic therapy and prompt irrigation of the flexor tendon sheath, traditionally performed in the operating room. With the acceptance of wide-awake local anesthesia no tourniquet (WALANT) hand surgery and its potential ability to minimize time to flexor tendon sheath irrigation, we sought to determine whether closed irrigation of the flexor tendon sheath could be safely and effectively performed in the emergency department setting with WALANT technique. Methods A retrospective review was conducted of the senior author’s hand surgery consultations over a 12-month period. Six patients were identified who were diagnosed with PFT and subsequently underwent irrigation of the flexor tendon sheath using WALANT technique. Patient outcomes such as length of hospital stay, need for reoperation, infectious etiology, perioperative complications, and postprocedure range of motion (ROM) were identified. Results Six patients with diagnosis of PFT underwent irrigation of the flexor tendon sheath in the emergency department with local anesthesia only. The irrigation procedures were all well-tolerated. One patient required reoperation due to lack of appropriate clinical improvement following initial irrigation. Four of 6 patients regained their preinjury ROM while the remaining 2 patients had mild proximal interphalangeal joint extension lag. There were no complications associated with the procedures. Conclusions Surgical treatment of PFT with closed irrigation of the flexor tendon sheath in the emergency department utilizing WALANT technique was safe, effective, and well-tolerated. Local anesthesia alone can be used effectively for irrigation procedures of the flexor tendon sheath.

Limited Flexor Sheath Incision and Drainage in the Emergency Department in the Management of Early Pyogenic Flexor Tenosynovitis

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.

Pyogenic Flexor Tenosynovitis as a Rare Complication of Dyshidrotic Eczema

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.

Development of a Murine Model of Pyogenic Flexor Tenosynovitis

ABSTRACTBackgroundTo demonstrate the plausibility of a murine model of pyogenic flexor tenosynovitis.Methods2μL of sterile PBS or bioluminescent Xen29 Staphylococcus aureus was administered to the tendon sheath of 36 male C57BL/6J mice. The infectious course was monitored by bioluminescence (BLI) signal via IVIS imaging and recording of weight change. The infected hind paws were harvested at four time points: 24 hours, 72 hours, 1 week and 2 weeks for histopathology using Alcian Blue hematoxylin staining. Two-way ANOVA with Sidak’s multiple comparison test was used for statistical analysis.ResultsThe infected cohort displayed significantly elevated bioluminescent values, reductions in weight, and exhibited swelling of the infected digit throughout the course of infection. By day 7 most infected mice saw a substantial decrease in BLI signal intensity, however two infected mice exhibited persistent BLI intensity through day 14. Histopathology of the infected cohort showed tissue disorganization and the presence of a cellular infiltrate in and around the flexor tendon sheath.ConclusionsA murine model of pyogenic flexor tenosynovitis is possible. Further optimization of the model offers an experimental platform for investigation of the pathophysiology of pyogenic flexor tenosynovitis.Clinical RelevanceThis animal model can be utilized in order to elucidate the basic molecular/cellular mechanisms of pyogenic flexor tenosynovitis while simultaneously evaluating novel therapeutic strategies.