Stenosing flexor tenosynovitis of the hand (trigger finger)

Trigger finger is the second cause of consultation with the hand surgeon. In 2009, Kerrigan published a strategy for the treatment of this pathology, which consists of two infiltrations with corticosteroids in the sheath of the flexor tendons at the level of the A1 pulley, followed by percutaneous or open surgical release, following the algorithm described by the author. 140 files that met the inclusion criteria were analyzed. It was found that the female gender is the most frequently affected during the sixth decade of life in 46%. The most frequently affected finger is the third, affects the right hand in 44% and both hands in 29%. 91% of the patients received a first infiltration and only 31% of these received a second infiltration. The surgical procedure was decided in 33% of the patients. The longest follow-up was 180 months and the shortest was 3 months with 100% of asymptomatic patients. The algorithm proposed by Kerrigan in the treatment of this pathology is a good strategy that has a high success rate without having to perform a surgical procedure as the first treatment option.

Case of flexor tenosynovitis caused by Mycobacterium arupense

Mycobacterium arupense is a member of the Mycobacterium terrae complex (MTC) that is implicated in bone and joint infections, among others. This group of environmental pathogens can be found in soil, reclaimed and drinking water systems, rodents, fish tanks and bioaerosols in duck houses. Interestingly, while M. arupense is genotypically closely related to the other agents in the MTC, antibiotic susceptibility of these mycobacteria can vary widely and empiric antibiotic therapy is controversial. Our case report contributes to the very limited literature on M. arupense tenosynovitis—as only six cases have been reported since 2008—and sheds light on different courses of treatment. While previous cases have been successfully treated, a streamlined course of therapy for M. arupense tenosynovitis is still needed.

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.

Gouty flexor tenosynovitis – Case report and review of the literature

Gout is a rare cause of tenosynovitis and is difficult to diagnose based on clinical symptoms and imaging modalities. We present a case of gouty tenosynovitis of the proximal interphalangeal joint. A 32-year old male patient presented with a swollen, painful proximal interphalangeal joint of the 3rd digit on his right hand for 2 weeks with flexion contracture. Surgical exploration of the affected joint revealed a gouty tophus with extensive infiltration of the underlying flexor tendon. A tenosynovectomy and flexor tendon release was performed to treat the flexion contracture. Pathology disclosed urate crystals deposited within the tendon. Gouty infiltration of the flexor tendons of the hand can lead to extensive damage and compromised function. A high level of clinical suspicion is required as gouty tenosynovitis is a rare presentation and can often mimic an infectious etiology. Keywords: Gout; Tenosynovitis; Flexor tendon; Hand; Tophi.

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.