REBEL Core Cast 77.0 – Pyogenic Flexor Tenosynovitis

Take Home Points

  • Think about flexor tenosynovitis in a patient with atraumatic finger pain.  They may have any combination of these signs:
    • Tenderness along the course of the flexor tendon
    • Symmetrical swelling of the finger – often called the sausage digit
    • Pain on passive extension of the finger and
    • Patient holds the finger in a flex position at rest for increased comfort
  • Give antibiotics to cover staph, strep and possibly gram negatives.
  • Get your surgeon to see the patient, while we can get the antibiotics started, these patients need admission and may require surgical intervention.

REBEL Core Cast 77.0 – Pyogenic Flexor Tenosynovitis

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Definition: Infection of the synovial sheath that surrounds the flexor tendon.

Epidemiology

  • Uncommon (<10%) of hand infections
  • Risk factors: IV drug use, immunocompromise, diabetes
  • Causative organisms
    • Staph aureus (most common)
    • Mixed flora and gram negative organisms more common in those with immunocompromise
    • Consider Pasteurella multocida in bites

Presentation

  • Clinical diagnosis – diagnostic tests can support the diagnosis but, cannot rule it out
  • Pain and swelling the most common symptoms + typically present over the palmar surface of a single digit
  • Kanavel’s Signs
    • Affected finger is held in flexion.
    • Passive extension causes pain.
    • Fusiform swelling of the affected digit.
    • Tenderness along the flexor tendon.
    • Performance characteristics (presence of all 4 signs) (Kennedy 2017)
    • Sensitivity: 91.4 – 97.1%
    • Specificity: 51.3 – 69.2%
    • LR (+): 2-3
    • LR (-): 0.04 – 0.16

Management

  • Elevation. Update tetanus
  • Consultation with orthopedics or hand surgery
    • May request lab tests (ie ESR, CRP and WBC) but, flexor tenosynovitis is a clinical diagnosis.
    • Patients will often require incision, drainage and debridement in the OR
  • Imaging
    • Plain radiographs can be useful if there is suspicion for a foreign body
    • MRI can identify inflammation but cannot definitely distinguish an infectious etiology 
  • IV antibiotics
    • Penetrating mechanism
      • Immunocompetent patient: Cefazolin 1-2 g IV q6-8h
      • Immunocompromised, Bite Injury
        • Ampicillin-sulbactam 1.5-3 g IV q6h OR
        • Cefoxitin 2 g IV q6-8h
    • Suspected disseminated gonococcal infection: Ceftriaxone 1 g IV q24h
    • Consider vancomycin if significant risk of MRSA (ie prior MRSA infections, IV drug use etc)

Take Home Points

  • Think about flexor tenosynovitis in a patient with atraumatic finger pain.  They may have any combination of these signs:
    • Tenderness along the course of the flexor tendon
    • Symmetrical swelling of the finger – often called the sausage digit
    • Pain on passive extension of the finger and
    • Patient holds the finger in a flex position at rest for increased comfort
  • Give antibiotics to cover staph, strep and possibly gram negatives.
  • Get your surgeon to see the patient, while we can get the antibiotics started, these patients need admission and may require surgical intervention.

Read More

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

Cite this article as: Anand Swaminathan, "REBEL Core Cast 77.0 – Pyogenic Flexor Tenosynovitis", REBEL EM blog, March 23, 2022. Available at: https://rebelem.com/rebel-core-cast-77-0-pyogenic-flexor-tenosynovitis/.

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