Orthopedics Book

http://www.fpnotebook.com/

Suppurative TenosynovitisAka: Pyogenic Flexor Tenosynovitis, Purulent Tenosynovitis, Kanavel's Cardinal Signs

Advertisement

  1. See Also
    1. Hand Infection
    2. Fight Bite
  2. Definition
    1. Infection within flexor tendon sheath
  3. Causes
    1. Extension of felon
    2. Puncture Wound of finger
    3. High Pressure Injection Wounds
      1. Paint injection (most toxic!)
      2. Oil or grease injection
    4. Disseminated Neisseria gonorrhoeae
  4. Risk Factors
    1. Immunocompromised patients (e.g. HIV Infection)
  5. Complications
    1. Contiguous spread of Infection throughout hand
    2. Associated with rapid increase in pressure
      1. Pus accumulation
      2. May obliterate tendon blood supply
      3. Results in tendon necrosis and function loss
  6. Signs
    1. Febrile and toxic appearing patient
    2. Kanavel's four cardinal signs
      1. Finger is uniformly swollen
      2. Finger held in slight flexion for comfort
      3. Course of inflamed sheath is markedly tender
      4. Passive finger extension causes intense pain
        1. Highly sensitive for flexor tendon infection
  7. Differential Diagnosis
    1. Subcutaneous abscess (localized tenderness)
  8. Diagnostics
    1. Ultrasound may show tendon effusion or abscess
  9. Management
    1. Early recognition and treatment is critical
    2. High dose antibiotics
      1. Initial parenteral antibiotics
        1. General coverage (Streptococcus, Staphylococcus)
          1. Cefazolin (Ancef) or
          2. Ampicillin-sulbactam (Unasyn) or
        2. Neisseria gonorrhoeae suspected
          1. Ceftriaxone (Rocephin)
          2. Fluoroquinolone
      2. Later oral antibiotics for home
        1. Continue for 5 to 14 days after discharge
    3. Extremity elevation and splinting
    4. Remove rings
    5. Early surgical evaluation
      1. Wide Incision and Drainage
        1. If no improvement in 24 hours with antibiotics
        2. Prevents tendon sloughing
    6. High Pressure Injection Wound treatment
      1. Requires extensive debridement and decompression
  10. References
    1. Boles (1998) Hand Clin 14:567
    2. Clark (2003) Am Fam Physician 68:2167

Navigation Tree