From the Guidelines
Flexor tenosynovitis is an infection of the flexor tendon sheath in the hand or fingers, requiring prompt treatment with antibiotics and often surgical intervention. Initial management includes immobilization, elevation, and empiric antibiotic therapy with coverage for Staphylococcus aureus and Streptococcus species, typically using cefazolin 1-2g IV every 8 hours or clindamycin 600-900mg IV every 8 hours for penicillin-allergic patients.
Key Considerations
- Surgical drainage is necessary in most cases, especially when Kanavel's four cardinal signs are present: finger held in slight flexion, uniform swelling, tenderness along the tendon sheath, and pain on passive extension.
- Early treatment is crucial to prevent complications such as tendon rupture, adhesions, joint contractures, or spread of infection to adjacent structures.
- The infection typically results from penetrating trauma, though it can also occur from contiguous spread from adjacent infections or hematogenous seeding.
- Without proper treatment, permanent hand dysfunction can result, making rapid diagnosis and appropriate management essential for preserving hand function.
- MRI is useful for diagnosing infectious and noninfectious tenosynovitis in both the flexor and extensor wrist compartments 1.
Diagnostic Approach
- Radiographs may be nondiagnostic, and MRI or US can be used as alternative initial examinations to evaluate fluid-filled and synovial-lined structures, including ganglia, cysts, bursa, and tendon sheaths.
- Occult ganglion cysts can be easily identified with MRI, but IV contrast may be necessary to distinguish ganglia from synovitis 1.
From the Research
Definition and Treatment of Flexor Tenosynovitis
- Flexor tenosynovitis is a severe infection of the hand with potentially disastrous outcomes, as recognized by studies such as 2.
- The mainstay of treatment has been emergent surgical washout, but recent evidence suggests potential for conservative management with a combination of intravenous antibiotics, elevation, and splinting 2.
Management Approaches
- A survey of hand surgeons found that almost 50% would proceed to surgical decompression and washout even in patients diagnosed early, increasing to 88% when treating a patient whose diagnosis was delayed 2.
- The use of closed-catheter irrigation systems, such as the On-Q delivery system, has been reported to allow for simultaneous in situ antibiotic and pain control for outpatient treatment of flexor tenosynovitis 3.
- Corticosteroid injections have been shown to be effective in treating flexor tenosynovitis, with symptoms and signs resolving in 61% of patients after a single injection 4.
Role of Antibiotics and Corticosteroids
- The use of antibiotics as a component of therapy has been shown to result in improved range of motion outcomes, as well as the use of catheter irrigation rather than open washout 5.
- Corticosteroids have been investigated as an adjunct to antibiotics and surgical drainage for the treatment of pyogenic flexor tenosynovitis, with studies suggesting that they can minimize the loss of range of motion typically associated with the condition 6.
Variations in Management
- There is substantial discrepancy regarding duration of immobilization, with some clinicians advocating for active mobilization either immediately or as soon as possible regardless of severity 2.
- Further investigation into the management and outcomes of flexor tenosynovitis is required to establish best practice guidelines for this rare but potentially devastating condition 2, 5.