Flexor tenosynovitis

Background

• Surgical emergency - flexor sheaths are contiguous with deep spaces of the hand
• Usually associated with a penetrating trauma

Clinical Features

Kanavel's Signs

• Pain with passive extension (often the first sign seen)
• Percussion tenderness (tenderness over entire length of flexor tendon sheath)
• Uniform swelling (symmetric finger swelling along length of the tendon sheath)
• Flexion posture (flexed posture of involved digit at rest to minimize pain)

Differential Diagnosis

Hand and finger infections

• Bed bugs
• Closed fist infection (Fight Bite)
• Hand cellulitis
• Hand deep space infection
• Hand-foot-and-mouth disease
• Herpetic whitlow
• Felon
• Flexor tenosynovitis
• Paronychia
• Scabies
• Sporotrichosis

Look-Alikes

• Digital mixoid cyst

Evaluation

Waterbath POCUS demonstrating fluid collection between tendon and bone

Workup

• CBC
• ESR
• Ultrasound
• Xray

Evaluation

• Generally a clinical diagnosis, based on history and physical exam
• Labs generally show elevated WBC and inflammatory markers
• Xray is done to rule out radiopaque foreign body

Management

• Emergent hand surgery consult in ED
• Antibiotics for most common skin pathogens Strep and Staph (start immediately if suspected but consider obtaining wound culture if any spontaneous drainage is present)
  • Vancomycin 1gm IV q12hr AND
  • Ampicillin/Sulbactam 1.5gm IV q6h OR cefoxitin 2gm IV q8h OR Piperacillin/Tazobactam 3.375gm IV q6h

• Special Antibiotic Considerations
  • Diabetic Patients ensure you have Pseudomonal Coverage by using Piperacillin/Tazobactam rather than Ampicillin/Sulbactam or cefoxitin
  • Marine Exposure consider adding a Fluroquinolone, Sulfamethoxazole/Trimethoprim or Doxycycline to cover common marine organisms

Disposition

• Admit

See Also

• Hand infection

Video

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