Flexor tenosynovitis

- Definition: o   Infection of the synovial sheath that surrounds the flexor tendon.

o   It’s a surgical emergency!!

-       Epidemiology

o   Incidence 2-9% of all hand infections

-       Risk factors

o   diabetes

o   IV drug use

o   immunocompromised patients

-       Mechanism

o   Penetrating trauma

o   direct spread from:

  • Felon
  • Septic joint
  • Deep space infection

-       Microbiology

o   Staph Aureus (40-75%)

o   MRSA (29%)

o   Strep

-       Presentation:

o   pain and swelling

  • typically presents in a delayed fashion (over last 24-48 hours)
  • usually localized to palmar aspect of one digit

o   Physical exam:

  • Kanavel signs:
  1. digit held in flexion
  2. tenderness to palpation over the tendon sheath
  3. pain with passive extension of the digit
  4. fusiform swelling of the digit

-       Imaging:

o   X-ray:

  • radiographs are not required, but may be useful to rule out a foreign object

o   MRI

  • cannot distinguish infectious flexor tenosynovitis from inflammatory but may help determine the extent of the ongoing process

-       Management:

o   Vancomycin + Cefepime

o   Call ortho! low threshold to take the patient to the OR for I&D once suspected (orthopedic emergency)

o   Nonoperative (rare)

  • Hospital admission, IV Abx, and hand immobilization
  • Indications:

o   early presentation

o   if signs of improvement within 24 hours, no surgery is required

Check out this 5 minute video from our amazing Dr. Anna Pickens!


Sources: Ortho bullets, EMin5, UpToDate