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Suppurative Tenosynovitis
Aka: Suppurative Tenosynovitis, Infective Tenosynovitis, Pyogenic Flexor Tenosynovitis, Purulent Tenosynovitis, Kanavel's Cardinal Signs
- See Also
- Hand Infection
- Fight Bite
- Definition
- Closed space Infection within hand flexor tendon sheath
- Pathophysiology
- Synovial Fluid is an ideal medium for Bacterial growth
- Tendon sheaths have a poor vascular supply
- Synovial Fluid collection
- Causes: Organisms
- Most common causative organisms
- Staphylococcus aureus
- Streptococcus
- 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)
- 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)
- Risk Factors
- Immunocompromised patients (e.g. HIV Infection)
- Worse outcomes with >5 years of Tobacco Abuse
- More serious infections, delayed Wound Healing
- 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
- Efficacy
- Test Sensitivity: 91 to 97%
- Test Specificity: 51 to 69%
- Kennedy (2017) Hand 12(6):585-90 +PMID: 28720000 [PubMed]
- 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
- Diagnostics
- Ultrasound may show tendon effusion or abscess
- Management
- Early recognition and treatment is critical
- Consult hand surgery urgently (within 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
- Initial parenteral antibiotics
- 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
- Ceftriaxone (Rocephin)
- Older antibiotic regimens that may be considered in more mild, borderline cases (Streptococcus, Staphylococcus)
- Cefazolin (Ancef) or
- Ampicillin-sulbactam (Unasyn) or
- Later oral antibiotics for home
- Continue for 5 to 14 days after discharge
- Following initial surgical and antibiotics management
- Occupational therapy (hand therapy) Consultation
- Complications: Acute
- Contiguous spread of Infection throughout hand
- Associated with rapid increase in pressure
- Pus accumulation
- May obliterate tendon blood supply
- Results in tendon necrosis, function loss, and ultimately tendon rupture
- Complications: Chronic
- Chronic finger stiffness and reduced function
- Finger Amputation due to worsening infection
- References
- Hori (2015) Crit Dec Emerg Med 29(3): 2-7
- 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]