Flexor Tenosynovitis

• Necrotic tissue removal necessary

• Complications result from inadequate drainage of infection

Physical Examination

On presentation to the hand surgeon, the palmar wound was draining serous fluid and there was no flexor tendon function (Fig. 8—1). Flexor tendons were visible within the wound, with a significant amount of surrounding nonviable tissue. Further surgical intervention was deemed appropriate.

Diagnostic Studies

Anteroposterior and lateral radiographs of the left hand were positive for arterial calcification and soft tissue swelling.

Differential Diagnosis

Posttraumatic nonspecific inflammation Cellulitis

Pyogenic, fungal, or mycobacterial infection

Flexor tendon sheath infection with rupture of the flexor tendons

Septic arthritis


Foreign body

Flexor Tenosynovitis

Figure 8—1. (A) Ongoing palmar drainage and lack of wound healing following limited palmar drainage of suppurative ring finger flexor tenosynovitis. (B) Due to rupture of necrotic flexor tendons, the digit rested in full extension, rather than the characteristic semiflexed posture of flexor tenosynovitis.

Pyogenic Flexor Tenosynovitis Photo

Figure 8—1. (A) Ongoing palmar drainage and lack of wound healing following limited palmar drainage of suppurative ring finger flexor tenosynovitis. (B) Due to rupture of necrotic flexor tendons, the digit rested in full extension, rather than the characteristic semiflexed posture of flexor tenosynovitis.


The diagnosis was flexor tendon rupture secondary to suppurative flexor tenosynovitis. Kanavel outlined the four classic, cardinal signs of digital flexor tenosynovitis: (1) fusiform digital swelling, (2) semiflexed digital posture, (3) significant pain associated with passive extension of the digit, and (4) exquisite tenderness along the

Kanavel Signs Tenosynovitis

Pain to palpation over flexor tendon sheath

Diffusely swollen finger Increased pain

Interphalangeal joints rest in flexion

Figure 8—2. Kanavel's cardinal signs of suppurative digital flexor tenosynovitis are (1) fusiform digital swelling, (2) semiflexed digi tal posture, (3) pain with

Pain to palpation over flexor tendon sheath

passive digital extension, and (4) pain along the flexor tendon sheath. Pain with passive digital extension is the earli-

Kanavel's Four Signs of Flexor Tendon Sheath Infection est and most sensitive sign.

entire flexor tendon sheath (Fig. 8—2). All four signs are present in an advanced case and a combination of one or more signs is found in less severe cases. However, in this case, the semiflexed posture was not present as the flexor tendons had ruptured secondary to the advanced process.

High-dose parenteral antibiotic management should be instituted at the time of diagnosis and continued postoperatively. Cultures and sensitivities guide the choice of antibiotic management. An infectious disease specialist best manages complex antibiotic therapy. The risk of infections in high-risk individuals should play an important part in the diagnosis. Diabetes and peripheral vascular disease are associated with hand infections refractory to medical intervention. To prevent the serious sequelae of suppurative flexor tenosynovitis, the treating physician must maintain a high index of suspicion for this diagnosis. Adequate drainage of the flexor tendon sheath and removal of necrotic tissue were necessary.

Surgical Management

The transverse, open, draining, palmar wound was extended proximally ulnarward and distally radially, and full-thickness flaps were elevated. The flexor tendons were confirmed to be ruptured, and the edges of the tendons were quite friable. There was no frank pus present. With pressure over the palmar aspect of the digit, serous fluid could be expressed from the tendon sheath. The necrotic flexor tendons had become a protected focus of infection, necessitating their excision. With ring finger flexion, the distal tendons could be delivered into the palmar wound. An ulnar midaxial incision was begun distally at the level of the digital whorl and carried back to the ulnar midaxial line at the distal interphalangeal joint level and back to the ulnar midaxial line at the proximal interphalangeal joint level. Subcutaneous tissue was divided and a full-thickness volar flap was elevated containing the neurovascular bundles.

The flexor tendon sheath was opened proximally distal to the A-4 pulley. The profundus was divided distal to the A-4 pulley and was completely excised. The flexor superficialis was divided at its insertion and was completely excised. Aerobic and anaerobic cultures were obtained. The digital and palmar incisions were loosely approximated, leaving the transverse wound open. The wounds were dressed and a volar splint was applied, immobilizing the wrist in slight dorsiflexion.

Postoperative Management

The patient's postoperative care consisted of daily dressing changes and whirlpool therapy. Due to the patient's multiple drug allergies, no parenteral antibiotics were administered. Cultures were positive for Staphylococcus aureus susceptible to vancomycin, gentamicin, rifampin, Bactrim, and tetracycline. Infectious disease consultation was obtained. Two weeks postoperative, wounds were healing well with no evidence of active infection. As the protected focus of nonviable flexor tendon tissue had been removed, the decision was made in this complex case not to proceed with a vancomycin desensitization program. The surgical approach, independent of further antibiotic administration, resulted in healing and resolution of the infectious process.

Once the infection began to abate, a lighter dressing to enable early motion replaced the splint. Following wound healing, resolution of infection, recovery of passive motion, and the development of tissue equilibrium, delayed flexor tendon reconstruction may be considered in such cases.

Alternative Methods of Management

Selected early cases of flexor tenosynovitis may be managed with parenteral intravenous antibiotics, splinting of the hand in the functional position, and elevation. In early cases, Kanavel's signs are limited to pain with passive digital extension. More advanced cases are characterized by the additional findings of a semiflexed digital posture and pain along the entire flexor digital sheath. Significant improvement must occur within 24 hours with complete resolution of presenting signs by 48 hours. Patients initially presenting with all four of Kanavel's signs demand more urgent surgical intervention.

Closed tendon sheath irrigation is an excellent surgical management technique, which should be instituted early in severe cases and in those less severe cases that do not quickly respond to intensive antibiotic management. This technique requires a zigzag incision in the palm proximal to the A-1 pulley of the involved digit. At the proximal margin of the A-1 pulley, the flexor tendon sheath is excised, and cultures are obtained. A second incision is made in the midaxial line over the distal portion of the middle digital segment sheath distal to the A-4 pulley. A long 16- or 18-gauge flexible catheter is directed from the A-1 pulley into the flexor sheath for a distance of up to 1.5 to 2 cm. A small rubber drain is directed from the distal wound to beneath the A-4 pulley proximally. Following proximal wound closure around the catheter, the system is tested for patency by flushing the catheter with sterile saline and observing the effluent from the distal wound/drain. The hand is then immobilized with a splint secured by a soft dressing with the catheter and drain exposed. Postoperatively the sheath is continuously or intermittently flushed with saline. After 24 hours, if the signs of infection have resolved, then the catheter and drain are removed and mobilization begun.


The most important method for prevention of further complications is adequate drainage. If inadequate drainage occurs, adhesions, tendon rupture, and osteomyelitis can result. The use of antibiotic treatment in combination with inadequate drainage can result in the development of resistant organisms.

Suggested Readings

Burkhalter WE. Deep space infections. Hand Clin 1989;5:553-559.

Floyd WE III, Troum S, Frankle MA. Acute and chronic sepsis. In: Peimer CA, ed. Surgery of the Hand and Upper Extremity. 1st ed. New York: McGraw-Hill; 1996:1741.

Glass KD. Factors related to the resolution of treated hand Infections. J Hand Surg 1982;7A:388-394.

Kanavel AB. Infections of the Hand: A Guide to the Surgical Treatment of Acute and Chronic Suppurative Processes in the Fingers, Hand, and Forearm. Philadelphia: Lea & Febiger; 1912.

Kanavel AB. Infections of the Hand. 7th ed. Philadelphia: Lea & Febiger; 1943.

Mann RJ, Peacock JM. Hand infections in patients with diabetes mellitus. J Trauma 1977;17:376-380.

McGrath MH. Infections of the hand. In: May JW, Littler JW, eds. Plastic Surgery. Philadelphia: Saunders; 1990:5529-5556.

Neviaser RJ. Closed tendon sheath irrigation for pyogenic flexor tenosynovitis. J Hand Surg 1978;3A:462-466.

Neviaser RJ. Tenosynovitis. Hand Clin 1989;5:525-531.

Neviaser RJ. Infections. In: Green DP, ed. Green's Operative Hand Surgery. 3rd ed. New York: Churchill Livingstone; 1993:1021-1038.

Stern PJ, Staneck JL, McDonough JJ, et al. Established hand infections: a controlled prospective study. J Hand Surg 1983;8A:553-559.

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  • sara
    Which of kanavels signs are most sensitive?
    4 years ago
  • maribel
    Do you need all 4 signs of kanavels for tenosynovitis?
    2 years ago

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