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

Abstract

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.

Keywords

infection diagnosis flexor tenosynovitis emergency department treatment research and health outcomes tendon

Introduction

Pyogenic flexor tenosynovitis (PFT) is a closed-space infection of the flexor sheath in the hand that often results in debilitating hand dysfunction.^1,2 The aggressiveness of the infection and its associated morbidity make this condition one of the few emergencies in the field of hand surgery.³ Prompt diagnosis and treatment are critical as any delay in management can result in lifelong deficits.^4,5

Flexor tenosynovitis is identified clinically with the guidance of 4 Kanavel signs, which are pain with passive extension, flexor sheath tenderness, a semi-flexed position, and swelling of the affected digit.⁶ Physical examination along with an elevated white blood cell count (WBC) and inflammatory markers (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP]) increases suspicion for the diagnosis.⁷

The treatment paradigm for flexor tenosynovitis traditionally has been emergent washout of the flexor sheath in the operating room (OR).^8-10 Published literature has focused on the approach to surgical management and the effectiveness of minimally invasive techniques, such as closed catheter irrigation.^11,12 Conservative management with systemic intravenous (IV) antibiotics alone also has been suggested.^13-15 Reconciling these treatment strategies is difficult as there are no universally accepted selection criteria for patients who would benefit most from each approach.

The severity of flexor tenosynovitis occurs along a spectrum, first described by Michon in 1974.¹⁶ Appreciation of severity is important, as more severe diseases have been associated with worse functional outcomes.¹⁷ Studies focused on conservative treatment have distinguished between patients with true purulence within the flexor sheath, which we will call purulent pyogenic flexor tenosynovitis (p-PFT), and patients with early flexor tenosynovitis without frank purulence in the flexor sheath, which we will call nonpurulent pyogenic flexor tenosynovitis (np-PFT). Patients thought to have p-PFT were managed operatively, and patients thought to have np-PFT were managed with antibiotics alone.^13,18,19 Making this distinction is challenging, as clinical examination findings and laboratory data do not always correlate with purulence in the flexor sheath.²⁰ As a result, patients with np-PFT who could otherwise be managed conservatively may be subjected to the added morbidity and expense of an operative washout.¹³

The purpose of this study was to offer an alternative treatment strategy for suspected PFT with early decompression of the flexor sheath for patients with early flexor tenosynovitis or np-PFT. In our institution, patients with suspicion of PFT on examination undergo a limited incision and drainage (I&D) of the flexor sheath in the emergency department (ED). Patients found to have purulence in the flexor sheath after ED I&D are taken to the OR for definitive care. Patients confirmed to have np-PFT after limited release are then managed with culture-driven antibiotic therapy and observation.

We hypothesize that our treatment strategy would benefit patients with early flexor tenosynovitis through immediate intervention and a limited incision. In addition, a limited flexor sheath exploration can help distinguish patients with purulence in the flexor sheath from patients with np-PFT, thereby appropriately using OR resources. We present our safety and efficacy data for our series of patients managed with this approach.

Materials and Methods

A retrospective review of patient medical records was conducted using our institutional review board–approved hand surgery consult database. Medical records were reviewed for patients presenting to the ED of a high-volume academic medical center with potential flexor tenosynovitis requiring a hand surgery consultation between 2012 and 2019. We adhered to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for cohort studies in the design, execution, and reporting of the study.²¹

Study Population and Inclusion Criteria

We identified 70 patients for analysis. Inclusion criteria consisted of all adult patients with a concern for PFT based on clinical assessment and the presence of at least 1 Kanavel sign as described earlier.⁶ Patients with bilateral hand infections, repeat infections, delayed presentation (>7 days), and those who were severely immunocompromised (active chemotherapy, immunosuppressant medications, etc.) were excluded. A total of 34 patients met the inclusion criteria.

Bedside Limited Flexor Sheath I&D

Patients with suspicion for PFT entered into our treatment protocol (Figure 1). Patients with frank purulence on clinical examination were taken immediately to the OR for I&D and flexor sheath washout. Frank purulence was defined as draining purulence from a wound or the presence of a diffuse subcutaneous and/or palpable abscess. All other patients with PFT but without frank findings of purulence on examination underwent a limited bedside flexor sheath I&D in the ED (Figure 2). A designation of purulence after I&D was defined by the clinical provider as an overt thick, white, odorous fluid expressed from the hand. Any other fluid types including dark, cloudy, bloody, or clear fluid was deemed as nonpurulent and as a possible manifestation of early flexor tenosynovitis. No patients with suspicion for PFT based on the criteria listed above were managed with antibiotics alone.

A digital nerve block was performed using lidocaine with epinephrine for both a local anesthetic and hemostatic effect. The extremity was prepped and draped in the usual aseptic fashion. A sterile tourniquet was applied at the proximal aspect of the finger or wrist to further optimize visualization.

An oblique Bruner incision was made over the area(s) of concern. Incisions were carried through the skin, and blunt subcutaneous dissection was performed to expose the flexor sheath while protecting the neurovascular bundles. A longitudinal incision was made along the most volar aspect of the flexor sheath, taking care to protect the underlying flexor tendon. Abnormal fluid expressed either subcutaneously or from within the flexor sheath was cultured. The wound was irrigated with sterile saline fluid, and a bulky soft dressing was applied.

If purulence was encountered, patients were taken to the OR for management. The Michon classification was further used to characterize the fluid and subsequently the severity of infection, where stage I has serous exudate in the sheath, stage II has purulent fluid, and stage III has development of tendon or sheath necrosis.¹⁶

If no purulence was identified with limited incision, patients were admitted to the hospital and received IV antibiotics, interval warm water soaks, and close clinical monitoring. Once the infection resolved based on examination, patients were discharged from the hospital with a course of oral antibiotics, local wound care with daily warm water soaks and dressing changes (xeroform, gauze, kerlix), 1- to 2-week initial follow-up clinic visit, and an outpatient hand therapy referral.

Data Collection and Statistical Analysis

Demographic, outcome, and complication data were collected. The primary outcome was evaluating the safety of a limited flexor sheath I&D in the ED. Charts were reviewed for evidence of direct procedural complications, including flexor tendon injuries, digital artery injuries, and digital nerve injuries. The need for any subsequent operative intervention was also reported.

The secondary outcome of interest was treatment efficacy. Efficacy was studied directly using patient outcomes on follow-up visit. This included reporting the incidence of successful treatment with resolution of infection and functional outcomes using Cleveland grades. The Cleveland grading system is an objective assessment tool developed by Cleveland²² and was later modified by Grinnell.²³ It groups patients into poor, fair, good, and excellent grades based on range of motion seen on follow-up. Although it is not formally validated, Cleveland outcome grades have been used in studies evaluating patients with flexor tenosynovitis and is an effective tool in comparing outcomes among series.^11,22,23 Efficacy was also studied indirectly by reporting time to intervention and length of hospital stay.

Comparisons were made between the ED and OR I&D treatment groups. It is important to note that the ED and OR I&D groups are inherently different populations in our series. The ED I&D group consists of patients with np-PFT, and the OR I&D group consists of patients with p-PFT, therefore representing different disease severity. As a result, between-group comparisons were only calculated for variables where clinical outcome was independent of disease severity: safety and time to intervention. For the other variables, we performed pragmatic comparisons using published series of patients undergoing operative intervention for flexor tenosynovitis. Statistical analyses were performed. We report both descriptive statistics and comparison analyses using paired 2-sample t tests and χ² tests. Statistical significance was defined as a value of P ≤ .05.

Results

Thirty-four patients were treated for PFT over the 7-year study period, with an average follow-up of 2.7 months. Ten patients were acutely taken to the OR for frank p-PFT, and 24 patients underwent a limited flexor sheath I&D in the ED. Of patients who underwent ED I&D, 1 patient had purulence, requiring transition to immediate formal operative intervention. This patient was included in the OR I&D group for our results and subsequent analyses. The remaining 23 patients were deemed as np-PFT and were managed nonoperatively after bedside intervention.

Patient demographics are stratified by intervention (Table 1). The patients taken directly to the OR had more comorbidities. Findings were not found to be statistically significant, likely due to the small number of patients in that group.

Table 1.

Patient Characteristics for Patients With Flexor Tenosynovitis by Intervention Type (N = 34).

	Intervention type		P value
Patient Characteristics	ED I&D (n = 24)	OR (n = 10)	P value
Age (average)	43 years	46 years	.54
Female sex, %	41	50	.71
Tobacco use, %	37	50	.70
IVDU, %	16	0	.30
Duration of symptoms, d	2.5	3.0	.16
Traumatic mechanism, %	91	70	.11
Diabetes, %	17	40	.19
Hypertension, %	25	40	.43
Right hand dominance, %	88	80	.69
Digit affected, %^a			.26
Thumb	8	10
Index finger	29	40
Middle finger	42	40
Ring finger	0	10
Small finger	25	0
Follow-up time, mo	2.8	2.3	.67

Note. ED = emergency department; I&D = incision and drainage; OR = operating room; IVDU = intravenous drug use.

Summation greater than 100% due to multiple digits being affected in certain patients.

Clinical criteria used to identify patients with PFT are stratified by the type of intervention (Table 2). All patients in the OR I&D group had 3 or more Kanavel signs which significantly differed from the ED I&D group. The ESR and CRP were significantly higher in the OR I&D group, but patients in the ED I&D group had a wider variety of bacteria on culture. All patients in the OR I&D group were a Michon stage II or greater. No patients in this group had normal findings within the flexor sheath. In contrast, 96% of patients in the ED I&D group were stage I. No patients in the ED I&D group required a subsequent repeat intervention. Reoperation occurred in the OR I&D group in 30% of patients.

Table 2.

Diagnostic and Clinical Factors for Patients With Flexor Tenosynovitis Based on Intervention Type (N = 34).

	Intervention type		P value
Diagnostic Variables	ED I&D(n = 24)	OR (n = 10)	P value
Kanavel signs, type, %			<.01*
Pain on passive extension	75	80
Flexor sheath tenderness	92	100
Held in flexion	38	100
Fusiform swelling	46	90
No. of Kanavel signs			<.01*
1	3	0
2	8	0
3	11	3
4	2	7
Lab values
WBC	11.2 × 10⁹ cells/L	12.5 × 10⁹ cells/L	.35
ESR	26.4 mm/h	92.0 mm/h	<.01*
CRP	20.7 mg/L	153.4 mg/L	.06
Wound cultures, No.			<.01*
MSSA	9	1
MRSA	1	1
Beta-hemolytic streptococcus	3	1
Polymicrobial	1	3
Other	3	4
No growth	7	0
Michon classification, %			<.01*
Stage I	96	20
Stage II	0	40
Stage III	4^a	40

Note. ED = emergency department; I&D = incision and drainage; OR = operating room; No. = number; WBC = white blood cell; ESR = erythrocyte sedimentation rate; CRP = C-reactive protein; MSSA = methicillin-sensitive Staphylococcus aureus; MRSA = methicillin-resistant Staphylococcus aureus.

Patient was transitioned to operative intervention.

Statistical significance (P ≤ .05).

The primary outcome of interest was safety of performing a limited flexor sheath I&D in the ED (Table 3). Among the patients undergoing ED I&D, there were no procedural complications (flexor tendon, digital nerve, or digital artery injury). Similarly, there were no instances of the same procedural complications in the OR I&D group.

Table 3.

Patient Outcomes by Intervention Type With Comparisons to Published Controls (N = 34).

	Intervention type		P value	Published controls
Patient Outcomes	ED I&D (n = 23)	OR (n = 11)^a	P value	Published controls
Resolution of infection, %	100	90	.29	—
Procedural complications, %	0	0	.54	—
Any adverse events, %	16	70	<.01*	38^b, 16^c
Amputation, %	0	20	.08	4.5^d
Cleveland score, %			<.01*
Poor	0	30		8^e
Fair	14	70		17^e
Good	45	0		71^e
Excellent	41	0		4^e
Time to intervention, h	3.1	8.4	.05*	—
Length of hospital stay, d	3.0	7.1	<.01*	6.8^d

Note. ED = emergency department; I&D = incision and drainage; OR = operating room.

Based on final intervention (includes 1 patient transitioned from ED to OR).

Stern et al 1983.⁵

Lille et al 2000.²⁴

Giladi et al 2015.¹⁰

Born et al 2017.¹¹

Statistical significance (P ≤ .05).

The secondary outcome of interest was treatment efficacy (Table 3). There was no significant difference among amputations within the ED I&D group (0 of 24) compared with the OR I&D group (2 of 10). The ED I&D group had an overall adverse event rate at 16% (finger stiffness, adhesions, chronic pain, and delayed wound healing) compared with 70% in the OR I&D group. In both groups, finger stiffness was the most common adverse event seen on follow-up visit.

Patients in the ED I&D group had significantly shorter times to intervention when compared with the OR I&D group. The ED I&D group had an average 3-day hospital stay compared with a 7.1-day stay for the OR I&D group. In the ED I&D group, 86% had good/excellent Cleveland scores compared with 0 in the OR I&D group.

Discussion

We present our experience using a limited flexor sheath I&D in the ED for patients with PFT. Limited flexor sheath exploration appears to offer a treatment benefit for patients with early flexor tenosynovitis. Using this approach, we not only are able to provide immediate decompression, obtain a culture of abnormal fluid, and irrigate the flexor sheath but also are able to confirm the presence of overt purulence in the flexor sheath to guide treatment.

Clinical examination alone has not been shown to have consistent accuracy for identifying PFT. Kennedy et al²⁰ found that Kanavel signs have a high sensitivity but poor specificity for detecting flexor tenosynovitis. They calculated a positive predicted value (PPV) that ranged from only 62.7% to 72.7% for each of the Kanavel signs. When incorporating duration of symptoms of less than 5 days as well as their most robust predictors of PFT (pain with extension and tenderness along the flexor sheath), the authors were able to offer a clinical prediction tool with a receiver operating characteristic curve at 91%. Although an improvement over using Kanavel signs alone, this is still less than ideal when considering the potential impact of an incorrect diagnosis.

When considering laboratory data to help identify PFT in patients, Bishop et al⁷ found that an elevation of all 3 inflammatory markers (WBC, ESR, and CRP) was associated with a specificity and PPV of 100%. However, individual markers had poor sensitivity (39%, 41%, 76%) and a low negative predictive value (4%, 3%, 13%) for WBC, ESR, and CRP, respectively. In our data, 36% of patients with confirmed purulence in the flexor sheath had normal laboratory values, making these markers an inadequate means alone to rule out PFT.

Distinguishing p-PFT from np-PFT infections in patients is challenging, but few studies in our review of the literature have focused on the value of delineating these 2 disease types. Our data show that clinical examination alone is effective in diagnosing p-PFT using findings of overt purulence, with only 1 patient in our case series of 7 years demonstrating purulence in the flexor sheath after limited bedside flexor sheath I&D. However, it is important to note that abnormal fluid and/or positive bacterial culture for patients without overtly purulent flexor tenosynovitis were found in 71% of cases managed with limited bedside intervention. These patients in the referenced studies would have fallen under the category of p-PFT requiring formal operative intervention.^7,20 We believe that the data presented in this series offer a less invasive option for this subset of patients.

All 23 patients deemed to have early flexor tenosynovitis after limited flexor sheath I&D exhibited successful resolution of infection, and no patient required operative intervention after initial treatment in the ED. Patients undergoing ED I&D had an adverse event rate of 16%, with finger stiffness being the most common finding. Published rates of adverse events for patients managed operatively range from 16% to 38%.^5,24 Patients with early flexor tenosynovitis treated with ED I&D alone also exhibited good functional outcomes. We found that 86% of patients within the ED I&D group exhibited good/excellent Cleveland scores at a mean follow-up of 2 months. This is consistent with Born et al¹¹ who reported good/excellent results at 75% for 18 patients undergoing operative intervention for flexor tenosynovitis. Limited incisions have been thought to yield better outcomes secondary to a lesser burden of injury to the flexor sheath and overlying soft tissue.^25,26

In addition, we propose that immediate decompression of the infection has the added benefit of more expedient treatment compared with standard operative washout. The ED I&D group demonstrated a significantly shorter time to intervention at 3.1 hours versus 8.4 hours for patients going to the OR. Faster treatment and limited incisions may have resulted in the shorter observed hospital stay of 3.0 days seen in the ED I&D group compared with 6.4 days calculated from the pooled means of published series reported by Giladi et al.¹⁰

The value of this intervention is in part predicated on its safety. No patients who underwent ED I&D suffered major procedural complications, including injuries to the digital artery, nerve, and/or flexor tendon. Risks are minimized by a limited exposure, a centrally designed incision, and blunt dissection. More so, these procedures were conducted by trained residents who have received prior supervision and instruction from attending surgeons.

We also contend that bedside ED intervention provides treatment benefit over IV antibiotics alone for certain patients with early flexor tenosynovitis. In 1 series presented by DiPasquale et al,¹⁵ 12 patients without frank purulence on examination were treated successfully with IV antibiotics alone. Their study was limited by an inability to confirm purulence within the flexor sheath or positive cultures in these patients. As a result, their findings are confounded by the possibility that patients treated may have had other soft-tissue infections not involving the flexor sheath itself, which the authors themselves point out. For our patients who underwent limited bedside I&D, 71% of patients determined as having np-PFT or early flexor tenosynovitis had a positive culture yet still were able to avoid the OR. This finding supports the proposal that patients with early flexor tenosynovitis can possibly be managed without formal washout in the OR and highlights the value of a flexor sheath ED I&D, allowing for both the guidance of treatment in patients with equivocal examination findings and an immediate treatment benefit.

We agree that some patients with early flexor tenosynovitis may be able to be treated with IV antibiotics alone. However, patients in this study were ones who met criteria for PFT that otherwise would have been managed in the OR in most other institutions. As a result, our approach was to provide early decompression in the ED to immediately treat the infection and to determine whether there was progression to purulence in the sheath that would require operative treatment. The use of ultrasound to determine the presence or absence of fluid in the flexor sheath may help delineate a subset of patients with very early flexor tenosynovitis that may be better managed with IV antibiotics alone.²⁷

There are important limitations to this study to address. It was a retrospective case series with limited comparisons. The OR group were patients with p-PFT and more advanced diseases; therefore, conclusions were not able to be made on functional outcomes using this group alone. This limitation is in part mitigated by performing pragmatic comparisons using pooled means of published data in patients with flexor tenosynovitis treated in standard operative fashion. A randomized controlled trial evaluating a limited flexor sheath exploration in the ED compared with standard management could help further clarify these findings. This study also focused on immediate bedside I&D for early PFT compared with formal operative intervention without discussing which patients may benefit from IV antibiotics alone. Further research to uncover which patients would benefit from IV antibiotics alone would add to a more tailored treatment approach for patients with PFT based on disease severity.

In summary, we present an alternative approach to the management of patients with PFT. Patients with early flexor tenosynovitis can be effectively identified and treated with limited flexor sheath exploration in the ED, exhibiting a faster time to intervention and no greater rate of complications when compared with the OR group. There also appears to be a treatment benefit in terms of length of hospital stay and functional outcomes when compared with outcomes of patients published in the literature with PFT treated uniformly with operative intervention. No patients designated as np-PFT needed further operative intervention. Based on these results, patients presenting with suspected PFT could benefit from a limited bedside flexor sheath exploration to allow for early decompression of the flexor sheath, identification of purulence, and as a potentially definitive treatment for early flexor tenosynovitis.

Footnotes

Ethical Approval

This study was approved by our institutional review board.

Statement of Human and Animal Rights

This article does not contain any studies with human or animal subjects.

Statement of Informed Consent

This research was performed under the approval of our Institutional Review Board (IRB). No formal informed consent for research was required for the report and analysis of the data presented. All patients received standard of care at our institution. The patient image presented in excludes any patient identifying information. The patient signed an informed consent for this image to be included and can be provided as necessary.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Vinay Rao

Loree K. Kalliainen

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