A 23-year-old Thai female presented with a 2-day history of left ring finger pain. On examination, her ring finger was swollen, red, and she experienced severe pain with passive extension. She was diagnosed with pyogenic flexor tenosynovitis based on MRI findings and treated conservatively with antibiotics, splinting, and elevation. Surgical incision and drainage with postoperative irrigation would be considered if conservative treatment failed or for late presentations over 48 hours. The goals of treatment are to control infection, prevent stiffness and tendon necrosis, and allow for early rehabilitation.

1. Thorsang Chayovan
5th year medical student

2. ผู้ป่วยหญิงไทย อายุ 23 ปี
Chief Complaint :
เจ็บปวดที่ นิ้วนางมือซ้าย มา 2 วัน
Present History :
ปฏิเสธอุบัติเหตุ ขยับนิ้วนางปวดมาก ไม่มีไข้
 ตรวจร่างกาย นิ้วนางบวมแดง เจ็บเมื่อมีการขยับ

4.  Pain
 Stiffness
 Fever
 Previous history
 Underlying disease
 Systemic inflammatory disease manifestation
(RA, SLE, gout)
 Trauma history
 Lifestyle
 Family history

6.  Inspection
 Signs of Inflammation
 Deformities
 Evidence of trauma
 Palpation
 Stepping and crepitus
 Range of motion
 Neurovascular function

9.  Pain on active motion for 2 days
 Erythema and swelling
 Flexion deformity
 Severe pain on passive extension

11.  Infection
 Pyogenic FlexorTenosynovitis
 Acute osteomyelitis
 Cellulitis
 Septic arthritis
 Inflammation
 Systemic lupus erythematosus
 Rheumatoid Arthritis
 Gouty arthritis
 Trauma
 Fracture
 Dislocation

13.  X-rays: AP and lat. to rule out bony
involvement or foreign body
 MRI: Flexor tenosynovitis diagnosed by MRI
of the hand is a strong predictor of early RA

14.  Synovial Fluid Aspiration
 suppurative synovial fluid: culture
 nonsuppurative conditions: synovial fluid may show
▪ nonbirefringent crystals (gout)
▪ birefringent crystals (calcium pyrophosphate deposition
disease [CPPD] or pseudogout)
 CBC
 WBC count not elevated in nonsuppurative
conditions
 left shift is frequently present in acute processes

15.  ESR
 elevated in acute or chronic infections and may serve
as a marker to follow resolution of an infection
 not elevated in nonsuppurative conditions.
 Coagulation studies
 in anticoagulated patients or in patients with known
or suspected bleeding diathesis
 DIC:rare
 rheumatologic factor : rule out RA
 acid-fast bacilli and fungal cultures in patients
with chronic or atypical presentation.

16.  pathophysiologic state causing disruption of normal
flexor tendon function
 Cause
 Infection*
 secondary to acute or chronic inflammation as a result of
diabetes, overuse, or arthritis
 Septic FT : the 4 Kanavel signs
1) finger held in slight flexion
2) fusiform swelling
3) tenderness along the flexor tendon sheath
4) pain with passive extension of the digit

17.  orthopedic emergency
 closed-space infection
increased pressure
inhibits blood flow
tendon ischemia 
tendon necrosis and rupture

18.  Contiguous spread of infection
- radial bursa
- ulnar bursa
- horseshoe abscess
- midpalmar space
- thenar space
- Parona’s space

19.  Finger stiffness
 Vascular occlusion
 Tendon necrosis and function loss
 Median nerve compression

20. Principles
 Antibiotics
 Rest, splint and elevation
 Drainage
 Rehabilitation

21.  Conservative treatment
- within 24-48 hours after onset
- admission for empiric antibiotics and
observation
- splint (position of
safe immobilization)
- elevation

22.  Surgical treatment
- late presentation ( > 48 hours)
- conservative treatment failure
- abscess suspected : marked tenderness
- immunocompromised

23.  Incision and drainage with postoperative
closed irrigation
modified Neviaser technique

24. postoperative closed irrigation
- 30 ml of isotonic solution q 2 hours for 48
hours
- re-examine : off or continue?

25.  Rehabilitation
- ASAP (alleviation of inflammation)
- re-apply splint between exercise sessions
(for the first few days)

26. Incision here
or more!
 Open drainage : advanced infection and
necrosis that require debridement