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Year : 2020  |  Volume : 17  |  Issue : 2  |  Page : 65-68

Horseshoe swelling of the hand

Department of Orthopaedics, VPS Lakeshore Hospital, Kochi, Kerala, India

Date of Submission20-Jan-2021
Date of Decision22-Jan-2021
Date of Acceptance30-Jan-2021
Date of Web Publication08-Mar-2021

Correspondence Address:
N A Sukesh
Department of Orthopaedics, VPS Lakeshore Hospital, Kochi - - 682 040, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joasis.joasis_3_21

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Flexor tenosynovitis is a common hand infection and if not addressed early with effective treatment can result in permanent disability. A horseshoe abscess is a well-known aggressive variant of flexor tendon sheath infection occurring due to the spread of infection through the interconnections between the deep spaces of the hand. Early diagnosis and prompt and effective treatment are crucial in avoiding late complications. We report a case of horseshoe swelling of the hand following a penetrating injury treated successfully by surgical debridement and closed catheter irrigation.

Keywords: Flexor tenosynovitis, horseshoe abscess, kanavel sign, space of parona

How to cite this article:
Sukesh N A, Nasimudheen N, Theruvil B. Horseshoe swelling of the hand. J Orthop Assoc South Indian States 2020;17:65-8

How to cite this URL:
Sukesh N A, Nasimudheen N, Theruvil B. Horseshoe swelling of the hand. J Orthop Assoc South Indian States [serial online] 2020 [cited 2023 Apr 1];17:65-8. Available from: https://www.joasis.org/text.asp?2020/17/2/65/310997

  Introduction Top

Flexor tendon sheath infections are common and if not treated can end up with devastating complications including permanent functional impairment. The unique anatomic features of the flexor tendon sheath of human hand explain the spread of infection in this closed synovium-lined space which leads to the formation of “horse shoe” shaped swelling [Figure 1].
Figure 1: Flexor tendon sheath of fingers communicating with radial and ulnar bursae of the hand and proximal extension to space of Parona in distal forearm

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Flexor tenosynovitis is a closed space infection accounting for 2.5%–9.4% of all hand infections.[1] Horseshoe abscess is an aggressive variant of flexor tenosynovitis. We present a case of horseshoe swelling in the hand following a penetrating injury on the thumb which was managed successfully by surgical debridement and closed catheter irrigation.

  Case Report Top

A 67-year-old right-hand dominant male presented to our outpatient clinic with severe pain and swelling of the right hand. One week back, he had sustained a penetrating injury with a splinter onto the palmar aspect of his right thumb. He washed the hands and did not seek any medical attention as the wound was small. He took oral cefuroxime for 3 days. Five days following the injury, he started getting increasing pain in the whole of the hand. At the time of presentation, a week after the incident, he had numbness of lateral three fingers associated with increased pain, swelling, and stiffness. He had no constitutional symptoms.

Physical examination showed a small healed puncture wound at the volar aspect of interphalangeal joint of the right thumb [Figure 2]. There was diffuse edema of the right hand involving all the fingers, thenar area, and hypothenar area with a proximal extension of swelling across the wrist to involve the distal fourth of the forearm [Figure 3]. He also had positive Phalen's test and Tinel's sign suggestive of carpal tunnel syndrome. He was tender over the volar aspect of all fingers with reduced flexion suggestive of flexor tenosynovitis involving all five digits [Figure 4].
Figure 2: Healed puncture wound (red arrow) on the volar aspect of the interphalangeal joint of the right thumb

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Figure 3: Diffuse swelling of the right hand with involvement of the fingers, thenar, hypothenar, and also proximal extension into the distal forearm

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Figure 4: Inability to flex fingers and wrist of the right hand compared with normal hand

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Laboratory evaluation showed leukocyte count of 5.15 × 103/μL with 78.6% neutrophils (normal range: 42.2%–75.2%), erythrocyte sedimentation rate of 16 mm/h (normal range: 0–10 mm/h), and C-reactive protein 30 mg/L (normal range <10 mg/L). No foreign body/bony injury was visualized on the right-hand radiographs. An ultrasound imaging of the right hand could pick up a fluid collection around flexor tendons more in the region proximal to flexor retinaculum and the fluid was noted tracking along the tendon sheaths to all the fingers.

The patient was admitted for decompression of the carpal tunnel and exploration of flexor tendon sheaths. An incision was made on the volar aspect of the carpal tunnel and then extended proximally into the forearm. The carpal tunnel decompression was done by releasing the transverse carpal ligament. Synovium around flexor tendons appeared thickened and inflamed [Figure 5]. Tissue samples were sent for histology and culture. Next, a complete excision of the hypertrophied synovial tissue was done. The digital tendon sheaths were approached using two small transverse incisions. Distal incisions were made on the flexor crease at the level of distal interphalangeal (DIP) joints. For the thumb, a proximal incision was made at the level of metacarpophalangeal joint. The flexor tendon sheaths of remaining four fingers were exposed proximally by using two separate transverse incisions made at the distal palmar crease [Figure 6].
Figure 5: Intraoperative pictures showing inflamed and hypertrophic synovium in the flexor tendon sheath involving the bursae and Parona space in the distal forearm

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Figure 6: Incisions on the right hand: (yellow) carpal tunnel decompression, (black) proximal incision around the A1 pulley of fingers, (red) distal incisions on all fingers at distal interphalangeal joint to irrigate the flexor tendon she

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A 22 G/20 G (B BRAUN, Vasofix Safety 0.9 mm × 25 mm/1.1 mm × 33 mm) intravenous catheter was inserted into the flexor tendon sheaths at the proximal incisions after opening the A1 pulley [Figure 7]. Closed irrigation of digital tendon sheaths was done through the cannula using diluted povidone-iodine (Betadine microbicide) solution and normal saline. The outflow of irrigation fluid was noted at the distal incision over the DIP joints [Figure 8]. Skin incisions were closed with 4-0 Ethilon sutures and a sterile compression dressing was applied. His hand was actively mobilized the next day onward. The patient was given intravenous antibiotics (teicoplanin 400 mg and ceftriaxone 1 g) in the postoperative period. This was changed to oral antibiotics (clindamycin and ciprofloxacin) at the time of discharge.
Figure 7: 22 G cannula inserted into the flexor tendon sheaths at the proximal incisions after opening the A1 pulley and closed catheter irrigation done using betadine solution

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Figure 8: 20 G intravenous catheter inserted at proximal incision and the outflow of irrigation fluid seen (red arrow) at distal incision over distal interphalangeal joint

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Intraoperative cultures reported a few pus cells with no bacterial growth possibly because he was self-medicating with antibiotics. No tuberculous bacteria or granuloma was seen in his culture samples. The tissue biopsy was suggestive of inflamed synovium with patchy infiltrates of lymphocytes, neutrophils, and plasma cells. Postoperatively, the patient achieved a full range of active flexion and extension of fingers with complete relief of symptoms [Figure 9].
Figure 9: Right hand showing full range of movement in the immediate postoperative period

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  Discussion Top

Flexor tendon sheath of fingers is a synovium-lined, double-walled closed space, separated by the visceral and parietal layers.[2] The sheath extends from the mid-palmar space to the insertion of the flexor digitorum profundus tendon at the DIP joint of the fingers. The sheath of the thumb and little finger communicates with the radial and ulnar bursae, respectively. The two bursae communicate with each other and also with the space of Parona in the distal forearm. Studies[3],[4] have reported the presence of intercommunication between the two bursae (50%–80%), ulnar bursa with the index (5%), middle (4%), and ring fingers (3%).

Flexor tenosynovitis is mainly a clinical diagnosis. Several conditions such as cellulitis, necrotizing fasciitis, septic joint, rheumatoid arthritis, and gout show resemblance to flexor tenosynovitis. Kanavel[5] has described four clinical signs, although there is disagreement regarding the most reliable and most consistent sign. Hand radiographs are useful only in detecting bony injuries and retained foreign materials. An ultrasound is a simple and noninvasive tool not only to diagnosis but also to differentiate flexor tenosynovitis from its mimickers. The sonographic imaging, especially with the point-of-care ultrasound and water bath technique, appears to be less expensive, faster, and easily available compared to magnetic resonance imaging.[6]

The mainstay of treatment remains to be intravenous antibiotics with surgical drainage of the flexor tendon sheath. A limited incision with closed catheter irrigation has gained popularity as it has several advantages over the traditional techniques.[7] Neviaser[8] technique of catheter irrigation is the most commonly advocated method, although the technique of catheter irrigation was first described by Dickinson -Wright.

Prompt management of flexor tenosynovitis is essential to prevent serious consequences. Penetrating injuries of the hand need surgical debridement if there is any suspicion of tendon/sheath involvement. Whenever there is an infective tenosynovitis of the thumb or little finger, it is necessary to evaluate for proximal extension into the potential spaces of the hand/forearm to rule out a horseshoe abscess.

  Conclusion Top

Horseshoe infection is a rare variant of flexor tenosynovitis. Due to this rarity, lack of suspicion during early course of disease, and devastating late complications, it remains as a dreadful variant. Prompt diagnosis, timely interventions, and early mobilization are the key factors in preventing complications and providing a good functional outcome.

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Conflicts of interest

There are no conflicts of interest.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

  References Top

Pang HN, Teoh LC, Yam AK, Lee JY, Puhaindran ME, Tan AB. Factors affecting the prognosis of pyogenic flexor tenosynovitis. J Bone Joint Surg Am 2007;89:1742-8.  Back to cited text no. 1
Fussey JM, Chin KF, Gogi N, Gella S, Deshmukh SC. An anatomic study of flexor tendon sheaths: A cadaveric study. J Hand Surg Eur Vol 2009;34:762-5.  Back to cited text no. 2
Resnick D. Roentgenographic anatomy of the tendon sheaths of the hand and wrist: Tenography. Am J Roentgenol Radium Ther Nucl Med 1975;124:44-51.  Back to cited text no. 3
Aguiar RO, Gasparetto EL, Escuissato DL, Marchiori E, Trudell DJ, Haghighi P, et al. Radial and ulnar bursae of the wrist: Cadaveric investigation of regional anatomy with ultrasonographic-guided tenography and MR imaging. Skeletal Radiol 2006;35:828-32.  Back to cited text no. 4
Kanavel AB. The symptoms, signs, and diagnosis of tenosynovitis and fascial-space abscesses. Infect Hand 1912;1:201-26.  Back to cited text no. 5
Cohen SG, Beck SC. Point-of-care ultrasound in the evaluation of pyogenic flexor tenosynovitis. Pediatr Emerg Care 2015;31:805-7.  Back to cited text no. 6
Stefanovic MV, Sharpe F. Acute infections in the hand. In: Green DP, editor. Operative hand surgery. 5th ed., vol L New York: Churchill Livingstone; 2005. p. 55-94.  Back to cited text no. 7
Neviaser RJ. Closed tendon sheath irrigation for pyogenic flexor tenosynovitis. J Hand Surg Am 1978;3:462-6.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]


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