What is the treatment for flexor tenosynovitis?

Treatment of Flexor Tenosynovitis

The treatment of flexor tenosynovitis depends on whether it is infectious (pyogenic) or non-infectious, with infectious cases requiring prompt antibiotic therapy and often surgical intervention, while non-infectious cases can be managed with conservative measures including corticosteroid injections.

Diagnosis

Before determining treatment, proper diagnosis is essential:

• Clinical examination is the cornerstone for detecting tenosynovitis 1
• Ultrasound can confirm diagnosis with high specificity (80-94%) 2
• MRI provides detailed imaging of tendon changes with high sensitivity (95%) and specificity (95%) 1

Treatment Algorithm for Flexor Tenosynovitis

1. Infectious (Pyogenic) Flexor Tenosynovitis

Infectious tenosynovitis is a medical emergency requiring prompt treatment:

Early Presentation (Kanavel's signs present for <24-48 hours)

• First-line treatment:

  • Intravenous antibiotics (targeting Staphylococcus aureus)
  • Elevation and immobilization
  • Close monitoring 3

• If no improvement within 24-48 hours or worsening symptoms:

  • Surgical drainage and irrigation 4
  • Two-incision technique with catheter irrigation is most common 4

Established/Severe Infection

• Immediate surgical intervention with:
  • Surgical drainage and irrigation
  • Intravenous antibiotics
  • Consider adding corticosteroids as adjunctive therapy to reduce inflammation and improve range of motion 5

Antibiotic Recommendations

• Duration: 7-14 days (oral therapy appears effective after initial IV treatment) 6
• First choice: Amoxicillin + clavulanic acid for oral therapy 6

2. Non-Infectious Flexor Tenosynovitis

Conservative Management

• Rest and activity modification to prevent ongoing damage 1
• Ice therapy for 10-minute periods through a wet towel 1
• NSAIDs for pain relief (oral or topical) 1
• Splinting to reduce tendon irritation

Corticosteroid Injections

• Highly effective: Local corticosteroid injections resolve symptoms in approximately 61% of cases after a single injection 7
• Recurrence: Can be effectively re-treated with additional injections if symptoms return 7
• Success rate: Nearly 90% of non-infectious cases respond to medical management with corticosteroid injections 7

Surgical Management

• Reserved for cases that fail conservative treatment
• Digital flexor tendon tenotomy may be considered for non-rigid hammertoe with nail changes or excess callus 1

Special Considerations

Mycobacterial Tenosynovitis

• Requires specific antibiotic regimens:
  • For M. terrae complex: Consider macrolide plus ethambutol 1
  • For M. szulgai: Three to four-drug regimen for 12 months 1

Rheumatoid Tenosynovitis

• Early detection with ultrasound is important as tenosynovitis predicts erosive progression 2
• Treatment follows rheumatoid arthritis management protocols 1

Potential Complications

• Tendon adhesions and decreased range of motion
• Tendon rupture (particularly with repeated corticosteroid injections)
• Progression to compartment syndrome if untreated
• Digital ischemia in severe cases

Follow-up

• Regular monitoring of symptoms and range of motion
• Hand therapy for patients with residual stiffness
• Approximately 50% of patients with infectious tenosynovitis require hand therapy after resolution 3

Remember that early diagnosis and appropriate treatment are crucial to prevent long-term complications and preserve hand function, particularly with infectious tenosynovitis.