Changing patterns of septic tenosynovitis of the distal extremities

Abstract

The medical literature reports that human pyogenic tenosynovitis occurs almost exclusively in flexor tendons of distal extremities with only rare case reports in extensor compartments. We report a series of patients with septic extensor compartment tenosynovitis of the extremity. Twenty cases of septic tenosynovitis tendons of the wrist, hands, feet, and ankles were presented to our emergency department over a 4.17-year period, 15 men (one, twice over a 2.5-year span) and 4 women with an average age of 39 years. Diagnosis was made using CT (n = 6), MRI (n = 14), and in one case ultrasound (US). All cases were confirmed surgically. During the data collection period, no case of flexor septic tenosynovitis were presented. All patients were intravenous drug users. All imaging modalities showed fluid within the infected tendon sheaths and evidence of enhancement after contrast administration where contrast was administered. The single US showed hypervascularity on Doppler imaging. All wrist and hand infections (n = 15) occurred in the non-dominant hand, and all cases involved the fourth and next most commonly (n = 9 each) in the second and third extensor compartments. In the ankle and foot (n = 5), the extensor digitorum longus tendon was most commonly infected. Twelve patients (60 %) had soft tissue abscesses adjacent to infected tendon sheaths. The most common organism cultured from the tendon sheaths was Staphylococcus aureus, methicillin sensitive and resistant and often admixed with other flora. Common use of intravenous drugs now makes extensor septic tenosynovitis an important clinical diagnosis and likely now more common than flexor septic tenosynovitis.

Sonography of Non‐neoplastic Disorders of the Hand and Wrist Tendons

“…Sonographic features of infectious tenosynovitis include intrasynovial fluid, inhomogeneous tendon thickening, peritendinous edema, and hyperemia (Figures ) . These findings are, however, nonspecific; thus, a detailed knowledge of the medical history as well as a physical examination is crucial when considering other etiologies of tenosynovitis in the differential diagnosis (Figures and ).…”

Peroneal Tendon Reconstruction and Coverage for Treatment of Septic Peroneal Tenosynovitis: A Devastating Complication of Lateral Ankle Ligament Reconstruction With a Tendon Allograft

“…A retrospective review of 19 patients presenting to an emergency department with septic tenosynovitis of the upper extremity found that elevated ESR and CRP levels had no correlation with the presence of a closed space infection or later complications and that MRI and CT were beneficial in accurately diagnosing septic tenosynovitis. Contrast-enhanced MRI was found to be the most useful for the detection of associated deep space abscesses and closed space infections (18). Fluid >3 mm in the maximum width about the peroneal tendons on MRI has been reported as a finding consistent with peroneal tenosynovitis (30).…”

“…Septic peroneal tenosynovitis is even rarer and appears to have the potential for significant morbidity (1)(2)(3)(4)(5). Septic tenosynovitis has typically been more prevalent in the flexor tendons of the upper extremity (18). A retrospective review of 19 patients presenting to an emergency department with septic tenosynovitis of the upper extremity found that elevated ESR and CRP levels had no correlation with the presence of a closed space infection or later complications and that MRI and CT were beneficial in accurately diagnosing septic tenosynovitis.…”

“…Most of the published studies on flexor tenosynovitis have focused on the wrists and hands. Most of these cases have been secondary to atypical bacteria, fungus, or normal skin flora secondary to complications related to intravenous drug use (17,18). Only 4 case reports specific to septic peroneal tenosynovitis were found in the published studies.…”

Atraumatic Pyogenic Extensor Tenosynovitis of the Extensor Digitorum Longus

“…Most commonly documented in the literature of extensor pyogenic tenosynovitis are case reports in the upper extremities caused by atypical bacteria or fungi [ 3 , 4 ], with only two cases caused by Staphylococcus aureus [ 5 , 6 ]. In a case series of 20 patients with documented extensor pyogenic tenosynovitis, only five out of the 20 cases were in the foot/ankle region, and all of which were intravenous (IV) drug users [ 7 ]. It is rare for isolated tenosynovitis to occur in the extensor tendons of the lower extremity in a patient with no known trauma, IV drug use, or significant comorbidities.…”