Treatment Of Early Flexor Tenosynovitis In The Emergency Department
Vinay Rao, MD MPH, William K. Snapp, MD, Joseph Crozier, MA, Reena Bhatt, MD, Jinbo Tang, MD, Paul Liu, MD, Scott Schmidt, MD, Loree Kalliainan, MD FACS.
The Warren Alpert Medical School of Brown University, Providence, RI, USA.
Flexor tenosynovitis remains one of the most debilitating ailments in hand surgery. Treatment paradigm involves immediate washout of the flexor sheath in the Operating Room (OR) and systemic antibiotics to relieve the infection. Delay to intervention is associated with an increased risk for complications and patient morbidity. We present a novel approach in the management of patients with early flexor tenosynovitis, which includes immediate bedside incision and drainage in the Emergency Department (ED).
Retrospective analysis was performed on all adult patients that were treated for flexor tenosynovitis at our institution from 2012 to 2019. Diagnoses were made clinically using Kanavel signs. Patients with evidence of pyogenic flexor tenosynovitis on exam were taken straight to the OR. Patients with equivocal exam findings but with suspicion for early flexor tenosynovitis were treated with immediate bedside drainage in the ED. This included a limited incision, flexor sheath release, and copious irrigation. Patients found to have frank purulence in the flexor sheath subsequently underwent definitive operative washout. Demographic data was collected from patient medical records. The outcomes studied included the need for repeat definitive operative washout after initial ED intervention, time to intervention, complications rates and types, and the length of hospital stay. Comparisons were made using historical data.
In our study population, 40 patients met inclusion criteria. 63% (25/40) underwent immediate bedside drainage in the ED. Of the intervened on patients, 1 of 4 Kanavel signs were seen in 12%, 2 of 4 signs in 32%, 3 of 4 signs in 36%, and 4 of 4 signs in 20%. The rate of any complications for the bedside drainage cohort was 16% (4/25). There was no statistical significant difference when compared to complications rates for OR drainage published by Stern et al. 1983 (16% vs 38%, p=0.09). No patients suffered any immediate or severe complications, including digital nerve injuries, flexor tendon injuries, or other similar iatrogenic injuries. The most common complication was finger stiffness at 12% (3/25). Need for additional operative intervention despite ED drainage was seen in 16% (4/25) of patients. This group suffered no worse outcomes. Time to intervention in the ED was 3 hours versus time to intervention for patients going straight to the OR was 7.7 hours. The average length of hospital stay for the ED cohort was 3 days, compared to pooled means of 6.4 days for patients undergoing operative intervention seen in Chung et al. 2015, which was statistically significant (p=0.03).
Flexor tenosynovitis is one of the few emergencies in hand surgery and requires swift and definitive intervention. This condition represents a spectrum of disease from early infection to fulminant, pyogenic synovitis. For early flexor tenosynovitis, this study purports that immediate drainage in the ED allows for shorter time to intervention, shorter hospital length of stay, and is associated with no difference in complication rates when compared to historical controls. We suggest that bedside intervention for early flexor tenosynovitis is a safe strategy to provide the most expeditious treatment for this critical patient population.
Back to 2020 Posters