Back to Basics: Infectious Flexor Tenosynovitis (FTS)

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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.

Clinical presentation

  • 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

  1. Tintinalli’s Emergency Medicine, 7th edition
  2. Pang, et al. “Factors affecting the prognosis of pyogenic flexor tenosynovitis”. Journal of Bone and Joint Surgery. 2007;89(8):1742
  3. Bishop, et al. “The diagnostic accuracy of inflammatory blood markers for purulent flexor tenosynovitis”. Journal of Hand Surgery. 2013 Nov;38(11):2208-11
  4. Gilaldi, et al. “A systematic review of the management of acute pyogenic flexor tenosynovitis”. Journal of Hand Surgery. 2015 Sep;40(7):720-8

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