Tendon Sheath Infection

Question 1

What should be associated with a tendon sheath infection?

Answer 1

Cat bite

Question 2

What causes a tendon sheath infection?

Answer 2

1. Due to an infectious agent multiplying in an enclosed space of the tendon sheath
   *penetrating trauma/bite wounds (of extensors)
   *most common with the thumb and small finger

Question 3

What is the most common infectious agent?

Answer 3

1. Staph aureus
   *flexor tendons affected more commonly than extensor tendons

Question 4

How do tendon sheath infections happen?

Answer 4

1. Once bacteria enters between the inner visceral layer and outer parietal layer bacteria will grow

Question 5

What is the immune response?

Answer 5

1. Swelling and migration of inflammatory cells/mediators
2. Swelling and bacteria growth interfere with sliding mechanism of tendon
3. Pressure from the infection inhibit blood flow as well as the inflammatory process and cause tendon ischemia

Question 6

What are flexor tendon sheaths continuous with>

Answer 6

1. Ulnar and radial bursa in the palm respectively
   *there is risk of infecting the other digits as well

Question 7

Where else could the infection spread to?

Answer 7

1. Spread proximally along the tendon sheath into the wrist/forearm
2. Fasciae spaces/osseous structures/synovial joint spaces
3. Can erode through the layers of the skin

Question 8

What are the risk factors for a tendon sheath infection?

Answer 8

1. Animal handling
2. HIV/immunocompromised
3. Fist fighting

Question 9

What is the clinical presentation?

Answer 9

1. History of puncture wound, laceration or animal bite is common
2. Complaints of pain with movement
   *inability to use the affected hand or fingers

Question 10

What will be found on the PE?

Answer 10

1. Tenderness along the length of the affected finger/hand
2. Erythema
3. Edema
4. Warmth
5. Decreased ROM and muscle strength
6. Pain with PROM
7. Fever

Question 11

What are the 4 Kanavel sign?

Answer 11

1. Sausage digit
   *uniform swelling along entire finger
2. Held in passive flexion
3. Pain to percussion/Palpation flexor tendon sheath
4. Pain with passive extension

Question 12

What are some lab test to run?

Answer 12

1. Cultures
2. Cell count,crystals
3. CBC
   *WBC may be elevated
4. ESR
   *marker for resolution

Question 13

What will radiographs show?

Answer 13

1. A potential foreign body or bone involvement

Question 14

What are some complications?

Answer 14

1. Los of ROM secondary to adhesions
2. Soft tissue necrosis
3. Tendon rupture
4. Digital contracture

Question 15

What is the prognosis?

Answer 15

1. Poor if not treated or if significant delay in treatment
2. Good if patient presents early and is without comorbiidites

Question 16

What is the treatment?

Answer 16

1. Orthopedic emergency!!!! I&D, debridement
2. Resting/splinting
3. Elevation
4. Antibiotics (IV)
   *patient must be reevaluated within 12 hours