Etiology and Pathology
Acute suppurative tenosynovitis of the hand most commonly arises from secondary bacterial infection following puncture wounds. In some cases, it results from the spread of infection from the palm. The tendon sheaths of the thumb and little finger communicate with the radial and ulnar bursae, respectively, allowing tenosynovitis in these areas to spread to the corresponding bursae. Infection of the bursae can also extend through interconnections at the wrist and disseminate to the forearm. Infections of the tendon sheaths of the index, middle, and ring fingers are usually confined to their respective sheaths but may spread into the deep palmar spaces.
Clinical Manifestations
The inflammatory response progresses rapidly, with significant local and systemic symptoms developing within 24 hours. Affected fingers exhibit severe pain, accompanied by fever, headache, elevated white blood cell counts, and other systemic manifestations.
Suppurative Tenosynovitis
Involvement leads to uniform swelling of the proximal and middle phalanges of the affected finger, with the skin appearing extremely tense. The finger assumes a slightly flexed position, and there is marked tenderness along the tendon sheath. Passive extension of the finger exacerbates pain. Failure to promptly incise and decompress the infected sheath may result in ischemic necrosis of the tendon.
Suppurative Bursitis
With radial bursitis, there is swelling and slight flexion of the thumb, which cannot abduct or fully extend. Tenderness is present at the thumb and thenar regions. Ulnar bursitis presents with half-flexed posturing of the little and ring fingers, significant pain with passive extension, and tenderness in the little finger and hypothenar region.
Prevention and Treatment
The prevention of these infections relies on avoiding hand injuries and addressing wounds promptly. Early treatment follows the same approach as that for felon (purulent finger infection). In cases where initial treatment yields no improvement or when pronounced local swelling and pain occur, timely incision and decompression are necessary to prevent ischemic necrosis of associated tendons.
For suppurative tenosynovitis, incision and drainage may be performed along one side of the swollen tendon sheath, or bilateral incisions may be made for counter-drainage, ensuring that nerves and blood vessels are preserved. Incisions should avoid the transverse creases of the fingers and palm to minimize the risk of tendon injury.
For radial and ulnar bursitis, small incisions can be made on the palmar surfaces of the thenar and hypothenar regions, respectively, or counter-incisions may be employed for effective drainage. Proximal incisions near the wrist should be made no closer than 1.5 cm to the distal wrist crease to prevent injury to the median nerve. Postoperatively, elevation of the affected hand and immobilization in a functional position are indicated.