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

• 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)