Leave a comment
September 29, 2015 by dailybolusoflr
By: Casey Carr, MD
- Inflammation of a tendon and its synovial sheath.
- Most commonly in hand and wrist.
- Can have infectious and non-infectious causes.
- Infectious FTS is a surgical emergency.
- Presents as both an acute and sub-acute process
- Associated with penetrating trauma to the hand; this includes dog and cat bites or IV drug use.
- Can also be secondary to disseminated Neisseria gonorrhea.
- Kanavel’s cardinal signs: (1) proximal tenderness of the tendon sheath, (2) symmetric digit enlargement, (3) flexed joint at rest, and (4) painful passive ROM
- Earliest sign: pain with passive ROM
- Worst prognosis: age > 45, history of DM, PVD, CRF, and digital ischemia
- Primarily a clinical diagnosis
- XR if suspected retained foreign body
- If cutaneous purulent fluid present, send Gram stain and culture
- If systemic signs present, send blood cultures
- Inflammatory biomarkers (ESR, CRP, WBC) have high sensitivity but low negative predictive values
- Immobilize and elevate hand
- Consult hand surgery
- Parental antibiotics: Vancomycin 1 gram IV q 6 hours PLUS ampicillin-sulbactam 1.5 grams IV q 6 hours OR cefoxitin 2 grams IV q 8 hours OR piperacillin-tazobactam 3.375 grams IV q 6 hours
- Early use of broad spectrum antibiotics associated with better outcomes
- Tintinalli’s Emergency Medicine, 7th edition
- Pang, et al. “Factors affecting the prognosis of pyogenic flexor tenosynovitis”. Journal of Bone and Joint Surgery. 2007;89(8):1742
- Bishop, et al. “The diagnostic accuracy of inflammatory blood markers for purulent flexor tenosynovitis”. Journal of Hand Surgery. 2013 Nov;38(11):2208-11
- Gilaldi, et al. “A systematic review of the management of acute pyogenic flexor tenosynovitis”. Journal of Hand Surgery. 2015 Sep;40(7):720-8