- 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)
- Penetrating mechanism
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
- EMRAP HD: https://www.emrap.org/episode/flexor/flexor
- CoreP: https://www.emrap.org/corependium/chapter/recwTuItfsq5cWbsx/Tendinitis-and-Bursitis
- OrthoBullets: Pyogenic Flexor Tenosynovitis
- Kennedy CD et al. Differentiation between pyogenic flexor tenosynovitis and other finger infections. Hand 2017; 12(6): 585-90. PMID: 28720000
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/.