Contrast Enhanced Computed Tomography in the Diagnosis of Acute Pyogenic Flexor Tenosynovitis

The diagnosis of infectious flexor tenosynovitis (FTS) has historically been made based on physical exam using Kanavel's signs. The specificity of these findings has come into question. We looked to evaluate the use of contrast-enhanced computed tomography (CT) in increasing the successful diagnosis of FTS.

Two adult cohorts were formed, one of patients with FTS confirmed in the operating room and the second of patients with ICD.10 identified finger cellulitis (FC), without concomitant FTS. Demographics, laboratory values, CT scans, and examination findings were evaluated. Axial CTs were evaluated in the coronal and sagittal planes and tendon sheath/tendon width were measured. The tendon sheath/tendon was recorded as a ratio in the coronal (CR) and sagittal (SR) planes. Continuous and dichotomous variables were analyzed and measures of sensitivity, specificity, and predictivity were calculated. Seventy patients were included, 35 in the FTS cohort and 35 with FC.

A higher number of Kanavel signs were present in the FTS group (2.9 vs. 0.5, P < .05), with CR and SR both being significantly larger in the FTS group (P < .05). CR and SR cutoffs ≥ 1.3 provided high sensitivity, specificity, and positive predictive value (PPV) for FTS. Likelihood of FTS increased 5.9% and 5.5% for every 0.1 increase in CR and SR, respectively, with a 14% increase for every additional Kanavel sign.

In conclusion, CT ratios are useful in identifying FTS; and when used on their own or in combination with Kanavel's signs, CR and SR objectively improve the diagnosis of FTS.