In Brief: Kanavel's Signs and Pyogenic Flexor Tenosynovitis

High risk and low prevalence diseases: Flexor tenosynovitis

INTRODUCTION

Flexor tenosynovitis (FTS) is a deep space infection of an upper extremity digit which carries a high rate of morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of FTS, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

FTS typically occurs after direct penetrating trauma to the volar aspect of an upper extremity digit. Development of a deep space infection that quickly propagates through the flexor tendon sheath of a digit can result in serious structural damage to the hand and place the patient at risk for significant morbidity such as finger amputation or even result in death. Signs of FTS include symmetrical swelling of the affected finger, the affected finger being held in a flexed position, pain on any attempt of passive finger extension, and tenderness along the course of flexor tendon sheath, known as the Kanavel signs. Systemic symptoms such as fevers and chills may occur. Recognition of these signs and symptoms is paramount in diagnosis of FTS, as laboratory and imaging assessment is not typically diagnostic. ED management involves intravenous antibiotics and emergent surgical specialist consultation.

CONCLUSION

An understanding of the presentation and risk factors for development of FTS can assist emergency clinicians in diagnosing and managing this disease in an expedited fashion.

Pyogenic flexor tenosynovitis due to Kingella kingae in an infant

Pyogenic flexor tenosynovitis is relatively common but is seldom reported in young children. Kingella kingae is increasingly recognised as a causative agent. We report on an infant who presented with a palmar deep space infection and pyogenic flexor tenosynovitis caused by K. kingae K. kingae is a fastidious, often culture-negative, organism which has been increasingly recognised as a cause of paediatric orthopaedic infections, including flexor tenosynovitis. Clinical suspicion should be heightened, and antibiotic coverage broadened in the setting of a positive physical examination and negative blood cultures.

Antibiotics Versus Surgery in Treatment of Early Flexor Tenosynovitis

BACKGROUND

Treatment of pyogenic flexor tenosynovitis (FTS) historically involved surgical debridement supplemented with antibiotic therapy. No consensus exists on either: (1) the treatment algorithm for this infection; or (2) the clinical definition of "early" FTS. We performed a retrospective study to clarify indications for nonoperative management.

METHODS

We identified 40 patients with a diagnosis of FTS using Current Procedural Terminology and International Classification of Diseases, Tenth Revision, codes and a keyword search from an electronic medical record between 2011 and 2019. Patients underwent either surgical management (SG) (n = 20) or early antibiotics only (EAG) (n = 20). The surgical group was divided into patients with intraoperative purulence within the tendon sheath (PU) and those without purulence (NP).

RESULTS

The number of Kanavel signs and duration of days of symptoms were significantly greater in SG compared with EAG. Subgroup analysis of SG showed a greater number of days of symptoms in the NP group when compared with the PU group. No statistical significance was found with respect to age, smoking, or specific individual Kanavel signs between SG and EAG.

CONCLUSIONS

Both duration of symptoms and number of Kanavel signs should be considered in suspected early FTS. Patients with shorter duration of symptoms and fewer Kanavel signs were treated successfully with antibiotics alone. Operatively confirmed FTS presented more acutely with fewer days of symptoms and a higher number of Kanavel signs. Patients with subacute presentations may represent inflammatory conditions and hand infections other than FTS.

A Rare Cause of Chronic Flexor Tenosynovitis of the Finger

Cat scratch disease (CSD) is an uncommon condition. When a patient is infected, the disease is often self-limiting. Cat scratch disease involving the musculoskeletal system had been described, but the manifestation of the disease in hand remained unexplored. We report a case of chronic flexor tenosynovitis of the left index finger caused by cat scratch disease. In this case, the antibiotic treatment did not improve the clinical outcome. However, surgical debridement of the diseased finger resulted in a tremendous improvement in terms of pain and range of motion.

Surgical management of chronic calcific deposit resembling tendon sheath infection in the index finger: A rare case report and literature review

Background

Calcific tendonitis rarely occurs in the fingers, and it is easily misdiagnosed. Herein we describe the case of a patient with multiple calcific lesions within the flexor digitorum superficialis and the extensor digitorum tendons of the distal interphalangeal joints of the right index finger, and the surgical treatment of those lesions.

Case presentation

The patient was a 66-year-old man who reported pain and swelling in his right index finger for one year. He was diagnosed with chronic calcific tendonitis based on his symptoms and radiology images. He was successfully treated surgically, and histopathological examination confirmed the diagnosis. After one month, the patient had healed well, and there was no recurrence.

Conclusions

This is the first report of a patient suffering from chronic calcific tendonitis in a finger who failed conservative treatment and was successfully treated with surgery. The outcome demonstrates that surgical debridement can yield a good outcome in patients with chronic calcific tendonitis.

Progressive flexor tendon sheath infection on hand after needle puncture during surgery: a case report

Introduction

Flexor tendon sheath infection may be due to trauma, laceration, or bites, commonly directly inoculating the sheath. Kanavel cardinal signs in flexor tendon sheath infection cases consist of symmetrical swelling of the entire digit, a digit with semi-flexed posture, exquisite tenderness along the course of the tendon sheath, and pain with attempted passive extension of the digit. Elevated levels of inflammation markers such as white blood cell count, erythrocyte sedimentation rate, and C-reactive protein are often found in such cases. Flexor tendon sheath infections require immediate diagnosis and treatment to prevent poor clinical outcomes. This paper reports one case of severe flexor tendon sheath infection with poor outcomes that required ray amputation of the affected finger.

Case presentation

A 35-year-old Sundanese male presented to the emergency department with right middle finger pain accompanied with swelling, blister, and blackened color 24 hours after accidental puncture by suture needle during gynecologic surgery. The patient was a resident physician of the obstetrics/gynecology department. The finger was necrotic with blisters at the proximal phalanx of the palmar aspect. Both the palmar and the dorsal aspects of the hand were swollen and inflamed, with firmer swelling on the dorsal part. The necrotic area had extended to the middle phalanx. The patient has been diagnosed with flexor tendon sheath infection with compartment syndrome. Immediate surgical debridement and fasciotomy with shoelace technique at the distal interphalangeal joint were performed. On the initial presentation, erythrocyte sedimentation rate, white blood cell count, and C-reactive protein were elevated. Smear culture was negative. A clear boundary of necrosis at the level of the middle phalanx of the right middle finger was found; subsequently, disarticulation at the level of the distal phalanx was performed. A ray amputation was performed to preserve the hand’s function for performing surgeries in the future.

Conclusion

Prompt diagnosis and treatment of flexor tendon sheath infection are required to prevent complications. Progressive inflammation around infected soft tissue due to untreated tenosynovitis may lead to poor outcomes and may lead to the amputation of the affected finger. This condition may occur even in medical professionals; as such, awareness for proper protection during any medical procedure and prompt treatment-seeking are encouraged.

Use of antibiotics in pyogenic flexor tenosynovitis

Pyogenic flexor tenosynovitis is a frequent and serious condition. However, there is no consensus on the use of antibiotics. The objective of our study was to describe the treatment of this condition and to identify the surgical and medical management parameters to propose an effective and consensual postoperative antibiotic therapy protocol. We retrospectively reviewed pyogenic flexor tenosynovitis of the thumb or fingers treated between 01/01/2013 and 01/01/2018 at a teaching hospital. Inclusion criteria were confirmation of the clinical diagnosis intraoperatively and a minimum post-antibiotic follow-up of 6 months. Comorbidities, type of surgery, antibiotic therapy parameters, and treatment outcome were assessed. One hundred and thirteen patients were included. Fifty-four percent had comorbidities. The most frequent germ was staphylococcus, all patients received postoperative antibiotic therapy. Intravenous or intravenous followed by oral administration did not provide any benefit compared to an exclusively oral treatment (p = 0.46). The duration of postoperative antibiotic therapy (less than 7 days, between 7 and 14 days or more than 14 days) did not lead to any difference in healing rate (p = 0.67). However, treating for less than 7 days versus 7-14 days seemed to be associated with a higher risk of failure, although not statistically significant. Oral postoperative antibiotic therapy with amoxicillin + clavulanic acid for 7-14 days appears to be effective, allowing for outpatient management.

A Five-Year Retrospective Analysis of Diagnostic and Treatment Data of Flexor Sheath Infections: Can We Accurately Predict the Presence and Severity of Infection Prior to Surgical Washout?

Flexor sheath infections (FSIs) are soft tissue infections affecting the hand, which, if mismanaged, can have devastating consequences. Clinical assessment is key to diagnosis, with many relying on Kanavel cardinal signs as an aid. To prevent unnecessary operative intervention and the associated post-operative combined patient and healthcare burden, it is key that patients with FSIs are correctly identified. It would also be useful to stratify severity of FSIs without surgical exploration. To date, there is no accepted method to assist clinicians in doing so. We retrospectively analysed data from a five-year period to see if we could identify pre-operatively (a) accurate predictors of FSIs and (b) severity of the FSIs. We established that only the presence of all four Kanavel cardinal signs significantly predicted the presence of an FSI. No other variable that was available prior to surgery could predict either presence or severity of infection.

[Pyogenic Flexor Tenosynovitis]

Pyogenic flexor tenosynovitis (PFT) is still the most serious infections of the hand. If the typical cardinal signs of PFT according to Kanavel exist, the indication for surgery should be made immediately. The consequential damage of a delayed surgery with enormous restrictions on the movement of the fingers due to the destruction of the sliding layers and massive adhesions are so serious that conservative therapy attempts are very difficult to justify. The results of Hand therapy after delayed surgery are often disappointing. The rapid surgical intervention and the early opening and relief as well as the irrigation of the tendon sheath can end the disease, the destruction of the sliding layers and the severe pain almost immediately. Quick recognition and quick action are important. With early intervention, normal hand function can often be completely restored.

Diagnosis and Management of Common Hand Infections

While many hand infections are superficial, diligent evaluation, diagnosis, and treatment of these infections are central for preventing disability and morbidity. Maintaining a wide differential diagnosis is important as some hand infections may mimic others. In geographic areas with more than a 10% to 15% prevalence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) hand infections, empiric antibiotics should adequately cover MRSA. Once culture results are available, antibiotic regimens should be narrowed to reduce the development of resistant pathogens.

Ultrasound diagnosis of pyogenic flexor tenosynovitis in a 9-month-old infant: a rare case report

Pyogenic flexor tenosynovitis (PFT) is an aggressive infection of the flexor tendon sheath, requiring prompt intervention to minimize adverse outcomes. The diagnosis of pediatric PFT is often delayed due to the variable presence of Kanavel's signs in children and communication difficulties. A 9-month-old male presented to the emergency department with one of four Kanavel signs. The diagnosis of PFT was delayed until ultrasound was used to identify a fluid collection within the flexor tendon sheath. He was successfully treated with surgical debridement and antibiotic therapy, achieving full recovery by 6-month follow-up. This represents the youngest reported case of PFT. Difficulties with communication and physical exam as well as the variability of Kanavel's signs in young children can delay the diagnosis of pediatric PFT. Ultrasound can be a useful adjunct when clinical history and exam are equivocal, especially in children who present prior to language acquisition.

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.

Pyogenic Flexor Tenosynovitis: Evaluation and Treatment Strategies

Pyogenic flexor tenosynovitis (PFT) is a common closed-space infection of the flexor tendon sheaths of the hand, which remains one of the most challenging problems facing hand surgeons. PFT goes by several names including septic or suppurative flexor tenosynovitis. Adequate treatment requires timely diagnosis and often prompt surgical treatment. However, despite prompt treatment, and regardless of the protocol used, complication rates as high as 38% have been reported in the literature. Moreover, even with successful eradication of the infection, a significant proportion of patients will suffer from continuing pain, swelling, stiffness, loss of composite flexion, weakness, and recurrence potentially requiring amputation. This review will focus on current evidence-based antimicrobial and surgical treatment strategies to maximize treatment outcomes.

Pyogenic Flexor Tenosynovitis: Evaluation and Treatment Strategies

Pyogenic flexor tenosynovitis (PFT)is a potentially devastating closed-space infection of the flexor tendon sheath of the hand that can result in considerable morbidity. Management of PFT, regardless of the pathogen, includes prompt administration of empirical intravenous antibiotics and often surgical treatment. However, currently, there is no standardized treatment algorithm for PFT in regards to the need for, timing, or type of surgical treatment. Many utilize a combination of surgical decompression and sheath irrigation. However, despite prompt treatment, and regardless of the protocol used, complication rates can be high, leading to impaired function and even amputation of the affected digit. Further research is needed to elucidate the role of local antibiotics and corticosteroids in treating this condition and potentially preventing the morbid outcomes that are currently seen. This paper reviews the background, microbiology, and treatment options and controversies surrounding PFT.

Radiographic Soft Tissue Thickness Differentiating Pyogenic Flexor Tenosynovitis From Other Finger Infections

PURPOSE

Characteristic swelling has been described as a differentiating sign of pyogenic flexor tenosynovitis (PFT) but has not been validated. We conducted a retrospective study of adults with finger infections to compare radiographic parameters of soft tissue dimensions. Our hypothesis was that in patients with digit infections, radiographic soft tissue thickness measurement would differ between PFT and non-PFT infected digits.

METHODS

Patients with a finger infection and radiographic evaluation were identified retrospectively at a large academic medical center and divided into 2 groups: PFT (n = 31) and non-PFT infections (n = 31). We defined PFT as purulence in the tendon sheath or positive culture growth from the sheath at surgery. Non-PFT infections included all other finger infections such as abscesses and cellulitis. A total of 15 radiographic measurements were made on all included digits. Ratios and differences were calculated to characterize the pattern of swelling for each infected finger. Bivariate analysis was performed to identify potential predictor variables between the PFT and non-PFT groups. Logistic regression was performed to reduce confounding and model potential relationships.

RESULTS

Neither presence of diffuse swelling nor the shape of finger swelling distinguished PFT from non-PFT infections. All finger infections resulted in diffuse swelling. Pyogenic flexor tenosynovitis was distinguished by differential volar soft tissue thickness minus dorsal soft tissue thickness on radiographs at the proximal phalanx level (9 ± 1 mm for PFT vs 5 ± 1 mm for non-PFT). This was an independent predictor of PFT. The area under the receiver operating curve was 0.83 (95% confidence interval, 0.73-0.94). A difference between volar and dorsal soft tissue swelling of 7 mm or greater had a positive predictive value of 82% with a sensitivity of 84% and specificity of 74%. A difference of 10 mm predicted PFT infection with 76% probability (95% confidence interval, 73% to 99%).

CONCLUSIONS

Pyogenic flexor tenosynovitis may result in uniform finger swelling, but this does not appear to distinguish PFT from other finger infections. Acute PFT swelling is distinguished by differential volar versus dorsal radiographic soft tissue thickness at the level of the proximal phalanx. The term "fusiform swelling" is a misnomer for the appearance of acute PFT because the finger is not spindle-shaped.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.

Acute Calcific Periarthritis of the Hand: A Case Report in an Active Duty Soldier

Acute calcific periarthritis of the hand is a condition that can easily be misdiagnosed resulting in unnecessary diagnostic studies and treatment. The condition is thought to be benign with a self-resolving course. The author presents a case of an active duty 29-year-old male who presented to a military emergency department with severe atraumatic hand pain developing overnight with initial concern for flexor tenosynovitis. Following orthopedic consultation, he was determined to have acute calcific periarthritis of the small finger (metacarpophalangeal) MCP joint with resolution over approximately 3 weeks without recurrence over a 5-month period. This case report reviews the natural history of acute calcific deposits of the hand and its correct identification through clinical exam and plain radiographs to avoid unnecessary diagnostic testing and invasive surgical interventions.

Prediction of readmissions in the first post-operative year following hip fracture surgery

PURPOSE

To define risk factors for rehospitalization following fragility hip fractures and to create a predictive model.

METHODS

A retrospective cohort study of patients 65 years and older, who were treated operatively following fragility hip fractures between 01.2011 and 06.2016. Patients were allocated into two study groups based on the occurrence of recurrent hospitalizations in the year following surgery. Demographic information, comorbidities, and in-hospital characteristics were collected, as was information regarding 1-year readmissions. Multivariate analysis of factors predictive of rehospitalizations was performed, followed by a logistic regression using all predictors with p < 0.05. A stepwise backwards elimination method was used to create the predictive model.

RESULTS

Eight hundred and fifty-one patients were included; 369 (43.4%) had recurrent hospitalizations within the first post-operative year. Patients who were rehospitalized were more likely to be males, to use a walking aid and to live dependently. They had a higher age-adjusted Charlson's comorbidity index (ACCI) score, a higher perveance of atrial fibrillation, lower hemoglobin, worse renal function, less platelets, and longer time to surgery. Prevalence of in-hospital complications was similar. Six variables were found to independently influence the chance for readmissions: male gender, the use of a walking aid, higher ACCI score, lower hemoglobin, atrial fibrillation, and a longer surgical delay. Only the first four were found to be adequate predictors and were added to the prediction formula.

CONCLUSION

High 1-year readmission rates are seen following discharge in patients with fragility hip fractures. Addressing risk factors might aid to better rehabilitate patients and reduce morbidity.

Differentiation Between Pyogenic Flexor Tenosynovitis and Other Finger Infections

BACKGROUND

Hospital transfer decisions regarding pyogenic flexor tenosynovitis (PFT) are made difficult by emergency department presentations similar to other finger infections, with pain, redness, and functional limitation. Our objectives were to: (1) determine diagnostic sensitivity and specificity of Kanavel signs; and (2) identify existing factors most predictive of PFT during initial presentation.

METHODS

Adult patients who underwent surgical consultation for concern of PFT over a 5-year period were identified retrospectively. Bivariate screening identified clinical criteria for differentiation, and multivariate logistic regression was performed to control for confounding. We then created a prediction algorithm for diagnosis of PFT. Receiver operating characteristic (ROC) curve analysis was used to evaluate diagnostic accuracy.

RESULTS

Patients with PFT differed significantly from those with non-PFT finger infections in regard to the 4 Kanavel signs, duration of symptoms less than 5 days, and erythrocyte sedimentation rate. Sensitivity of the Kanavel signs ranged from 91.4% to 97.1%. Specificity ranged from 51.3% to 69.2%. Logistic regression identified independent predictors for PFT as tenderness along the flexor tendon sheath, pain with passive extension, and duration of symptoms less than 5 days. A prediction algorithm incorporating these 3 factors showed an area under the ROC curve of 0.91 (95% confidence interval, 0.840-0.979).

CONCLUSIONS

Kanavel signs have high sensitivity for detecting PFT but have poor specificity on an individual basis. Clinical prediction algorithms that combine the relevant factors may be helpful in the development of clinical prediction tools and educational materials for optimization of emergency hand care systems. Further prospective study is needed.

Polymicrobial pyogenic flexor tenosynovitis of the index finger and first ray resulting from autophagia

Pyogenic flexor tenosynovitis (PFT) is a well known infectious condition of the hand, involving the inoculation of the flexor tendon sheath with microorganisms. Many cases have been reported, common causes including direct inoculation by a puncture wound and deep lacerations extending into the flexor tendon sheath. In this report, we present a case of a 50 year old female with PFT resulting from autophagia (consuming one's own body parts, in our case, fingers) successfully treated with irrigation and debridement, amputation of the index finger at the metacarpophalangeal joint and antibiotic therapy.

Clinical Characteristics of Pyogenic Flexor Tenosynovitis in Pediatric Patients

PURPOSE

To characterize the clinical presentation, common pathogens, antimicrobial susceptibility, and treatment methods associated with pyogenic flexor tenosynovitis (PFT) in pediatric patients.

METHODS

Patients who underwent surgical treatment for PFT at a large tertiary-care children's hospital between 2001 and 2015 were identified. Descriptive summary statistics were reported on patient demographics, presenting symptoms and clinical examination features, culture results, treatment strategies, and early complications.

RESULTS

Thirty-two patients (71.9% male) with a mean age of 9.5 ± 5.5 years (range, 0.8-19 years) were included. At least 3 Kanavel signs were present on presentation in 62% of the cohort, with all 4 signs identified in 34%. Three children (9%) presented with 0 to 1 Kanavel signs, with semiflexed posturing of the digit as the least commonly (41%) manifested sign. The most frequently cultured organisms were methicillin-resistant Staphylococcus aureus (MRSA) (38%), methicillin-sensitive S. aureus (22%), and Pasteurella multocida (13%). Multiple organisms were cultured in 19% of cases. Intravenous antibiotics were administered for a median duration of 4 days (range, 1-16 days) in all cases. Organisms were sensitive to the initial antibiotic regimen in 81% of cases. All methicillin-resistant S. aureus infections were sensitive to vancomycin and trimethroprim-sulfamethoxazole, and 83% were sensitive to clindamycin. Incision and drainage (I&D) was performed in all cases, with 18% of patients requiring repeat I&D. Surgical approaches included limited incision (80%), midaxial incision (13%), and Bruner incision (7%). The average length of hospitalization was 5.1 days. Infection resolved in all cases without readmission. No neurovascular complications were identified.

CONCLUSIONS

The presence of Kanavel signs at presentation are a meaningful indicator of PFT, but are not uniformly present on examination in children and adolescents. Owing to the prevalence of antimicrobial resistance and polymicrobial infection, empirical antibiotic therapy using broad-spectrum agents with MRSA coverage is essential. In our cohort of pediatric patients with PFT of sufficient severity to warrant surgical management, prompt I&D along with culture-guided antibiotics predictably resolves infection.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Flexor Tenosynovitis

For patients with suspected flexor tenosynovitis, the mainstay of diagnosis is a thorough history and physical examination. The examination is guided by evaluating the patient for Kanavel's four cardinal signs. Empiric antibiotics should be started immediately on diagnosis covering skin flora and gram-negative bacteria. Typically, surgery is required. Appropriate exposure is required for adequate treatment and incisions should be tailored to preserve areas of skin compromised from draining sinuses and abscess pressure. Diabetes mellitus and peripheral vascular disease place patients at higher risk of poor outcomes including stiffness and amputation; early administration of antibiotics is the intervention that correlates most closely with good outcomes.

Pyogenic Flexor Tenosynovitis in an Infant

Pyogenic flexor tenosynovitis is a rare, though well known infectious process of the flexor tendon sheath of the hand. This condition is generally diagnosed in adults by the observance of the four Kanavel signs. Application of the Kanavel signs to diagnosis in the pediatric population, however, is of unknown utility. We present the case of a 13-month-old male with pyogenic flexor tenosynovitis who presented with all four of the Kanavel signs.

Treatment of digital pyogenic flexor tenosynovitis: single open debridement, irrigation, and primary wound closure followed by antibiotic therapy

INTRODUCTION

Digital pyogenic flexor tenosynovitis requires fast, aggressive treatment. Although this infection occurs frequently, treatment consensus is lacking.

MATERIALS AND METHODS

Between 2011 and 2015, 22 patients with acute pyogenic flexor tenosynovitis were treated with a single open debridement followed by irrigation; the incision was closed and a 10-day antibiotic course was administered. The average incision-to-suture time was 25 min, and the average hospital stay was 4 days. Recovery was uncomplicated for 20 patients, while two were reoperated, one due to germ resistance and the other due to necrotizing fasciitis. At an average of 30 month postoperatively, 21 of the 22 patients were available for follow-up. The affected finger was inspected, and sensibility, range of motion, and grip force were compared with the opposite side, and the DASH score was determined. Each patient documented pain in the affected finger at rest and during activity, and rated overall satisfaction with the treatment on a visual analogue scale.

RESULTS

Almost all patients were free of pain at follow-up and very satisfied. Compared to the contralateral side, each of the affected fingers had the same range of motion and sensibility. Grip force was similar on both sides. The average DASH score was 35 points.

CONCLUSION

A single open debridement with irrigation and primary wound closure followed by 10 days of antibiotic treatment resolved uncomplicated pyogenic flexor tenosynovitis. After 2 and a half years, the treatment yielded high patient satisfaction with neither functional nor subjective impairment of the affected finger.

The clinical and microbiological profile of the diabetic hand: A retrospective study from South India

BACKGROUND

Pyogenic Infections of the hand in diabetes are largely a tropical entity and published material in the area are rather meagre.

PATIENTS AND METHODS

This is a retrospective study on the pattern of hand infections and involves the microbiological profile of 39 cases of diabetes hand-related infections admitted to the hospital between the years 2004 and 2010.

RESULTS

This study included 39 patients, among whom 23 (59%) had necrotizing fasciitis (NF), and 16 (9-abscess and 7-tenosynovitis) had nonnecrotizing infection. Among 25 culture positive patients, polymicrobial infections were isolated in 13 (52%) patients, a single organism was isolated in 9 (36%) and 3 (12%) had sterile cultures. Out of the 41 different bacterial isolates, 51.12% were Gram-negative and 48.78% were Gram-positive. Patients with NF had a higher mean glycated hemoglobin (10.83 ± 2.59 vs. 8.64 ± 1.8%, P = 0.020), when compared to the nonnecrotizing group. Patients with NF also had more polymicrobial infections (P = 0.017), and a longer duration of hospitalization when compared to patients without NF (21.8 ± 9.96 vs. 12.7 ± 14.5 days, P = 0.021). Seven (17.94%) patients required amputation of the affected digits of which six (15.38%) had NF.

CONCLUSION

Patients with poor glycemic control, polymicrobial infection, delay in presentation, and a prior surgical intervention at another medical center was associated with more severe necrotizing infections. The duration of hospitalization and amputation rates was greater among patients with NF.