II. Definitions
- Suppurative Tenosynovitis
- Closed space Infection within hand flexor tendon sheath
III. Epidemiology
- Suppurative Tenosynovitis accounts for 3 to 9% of all Hand Infections
IV. Pathophysiology
- MIcrobial infection within the flexor tendon sheath
-
Synovial Fluid is an ideal medium for Bacterial growth
- Tendon sheaths have a poor vascular supply
- Synovial Fluid collection
V. Causes: Organisms
- Most common causative organisms (30 to 80% of cases)
- Other infections
- Gram Negative Bacteria (10% of responsible organisms)
- Disseminated Neisseria gonorrhoeae
- Disseminated Candida albicans (Immunocompromised patients)
- Mixed oral anaerobic and aerobic Bacteria (Injection drug use)
VI. Mechanisms
- Deep penetrating wound to the palmar surface of the hand or finger (most common)
- Blunt Hand Trauma
- Extension of felon
- Puncture Wound of finger
-
High Pressure Injection Wounds
- Paint injection (most toxic!)
- Oil or grease injection
- Disseminated Infection (e.g. Neisseria gonorrhoeae)
VII. Risk Factors
- Immunocompromised patients (e.g. HIV Infection)
- Worse outcomes with >5 years of Tobacco Abuse
- More serious infections, delayed Wound Healing
VIII. Signs
- Febrile and toxic appearing patient
- Kanavel's four cardinal signs
- Findings
- Finger is uniformly swollen (digital fusiform swelling)
- Finger held in slight flexion for comfort
- Course of inflamed sheath is markedly tender
- Passive finger extension causes intense pain
- Highly sensitive for flexor tendon infection
- Tender to percussion along the flexor tendon sheath
- Efficacy
- Findings
IX. Differential Diagnosis
- Deep space abscess (localized tenderness)
- Felon
- Cellulitis
- Animal Bite
- Clenched-fist Injury (Fight Bite)
- Necrotizing Fasciitis
- Disseminated Candida albicans (Immunocompromised patients)
- Disseminated Neisseria gonorrhoeae
- Osteomyelitis
- Septic Joint
X. Labs
- Inflammatory markers
- White Blood Cell Count elevated
- Erythrocyte Sedimentation Rate (ESR) elevated
- C-Reactive Protein (CRP) elevated
- Efficacy
- High Test Specificity 100% and Positive Predictive Value 100% for surgical management indications
- However, very low Test Sensitivity 39 to 76%, and low Negative Predictive Value 4 to 13%
- Bishop (2013) J Hand Surg Am 38(11): 2208-11 [PubMed]
XI. Imaging
- Imaging is optional and not fully diagnostic for Suppurative Tenosynovitis
- Although imaging may offer supportive evidence, flexor tenosynovitis is a clinical diagnosis
-
Ultrasound
- May show tendon effusion within sheath or abscess
- Efficacy in Suppurative Tenosynovitis
- XRay
- May demonstrate radiopaque retained soft tissue foreign body
- MRI Hand
- Most sensitive imaging modality for clear definition of involved structures
XII. Management
- Early recognition and treatment is critical
- Consult hand surgery urgently (within 24 to 72 hours)
- Hand surgery indications: No improvement in 24 hours of Antibiotics
- Minimal incision with catheter irrigation of tendon sheath (preferred) OR
- Wide Incision and Drainage
- May be indicated in High Pressure Injection Wound
- Extremity elevation and Splinting
- Remove rings from fingers
- Tetanus Prophylaxis
- Management based on Kanavel signs
- Kanavel Signs 3 to 4
- Intravenous Antibiotics and urgent surgical evaluation for intervention
- Kanavel Signs 2
- Intravenous Antibiotics, hospital observation and surgical Consultation
- Kanavel Signs 0 to 1 (typically early presentation in first 48 hours)
- Initial home management on oral Antibiotics with 24 hour follow-up
- Outpatient Antibiotics and close interval follow-up may be continued if patient is improving
- However, implement IV Antibiotics and urgent surgical evaluation for worsening
- Kanavel Signs 3 to 4
- Initial ParenteralAntibiotics
- First-line Parenteral coverage for MRSA
- Vancomycin
- Daptomycin
- Linezolid
- Televancin
- Clindamycin (depending on local sensitivities to MRSA)
- Injection drug use (polymicrobial coverage as well as MRSA)
- Vancomycin AND
- Piperacillin/Tazobactam (Zosyn)
- Disseminated Neisseria gonorrhoeae suspected
- Older Antibiotic regimens that may be considered in more mild, borderline cases (Streptococcus, Staphylococcus)
- Cefazolin (Ancef) or
- Ampicillin-sulbactam (Unasyn) or
- First-line Parenteral coverage for MRSA
- Later oral Antibiotics for home
- Continue for 5 to 14 days after discharge
- Following initial surgical and Antibiotics management
- Occupational therapy (hand therapy) Consultation
XIII. Complications: Acute
- Contiguous spread of Infection throughout hand
- Proximal extension of deep space infection up the arm may also occur
- Associated with rapid increase in pressure
- Pus accumulation
- May obliterate tendon blood supply
- Results in tendon necrosis, function loss, and ultimately tendon rupture
XIV. Complications: Chronic
- Chronic finger stiffness and reduced function
- Finger Amputation due to worsening or recurrent infection
XV. References
- Hori (2015) Crit Dec Emerg Med 29(3): 2-7
- McGowan (2023) Crit Dec Emerg Med 37(4): 18-9
- Boles (1998) Hand Clin 14:567-78 [PubMed]
- Clark (2003) Am Fam Physician 68:2167-76 [PubMed]
- Mamane (2018) J Orthop 15(2): 701-6 [PubMed]
- Rerucha (2019) Am Fam Physician 99(4):228-36 [PubMed]