What is the treatment for flexor tenosynovitis?

Treatment of Flexor Tenosynovitis

The treatment of flexor tenosynovitis requires prompt intervention with antibiotics and often surgical decompression, especially for pyogenic (infectious) cases, while non-infectious cases may respond well to corticosteroid injections.

Types of Flexor Tenosynovitis

Infectious (Pyogenic) Flexor Tenosynovitis

Pyogenic flexor tenosynovitis (PFT) is a severe infection of the hand's flexor tendon sheath that requires immediate treatment to prevent devastating outcomes 1.

Clinical Presentation

• Characterized by Kanavel's four cardinal signs:
  • Symmetrical swelling of the affected finger
  • Finger held in a flexed position
  • Pain on passive extension
  • Tenderness along the flexor tendon sheath 1
• Systemic symptoms may include fever and chills

Management Algorithm for Pyogenic Flexor Tenosynovitis

1. Initial Management (Emergency Department)

   • Prompt administration of empirical intravenous antibiotics
   • Emergency surgical consultation 1, 2
   • Elevation of the affected hand

2. Surgical Management

   • Nearly 50% of clinicians proceed to surgical decompression even in early diagnosed cases
   • This increases to 88% when diagnosis is delayed 3
   • Surgical techniques:
     • Most surgeons use general or regional anesthesia
     • Two-incision technique with catheter irrigation is common 3
     • Closed-catheter irrigation systems (e.g., On-Q delivery system) can deliver antibiotics and pain medication simultaneously 4

3. Post-Surgical Care

   • Mobilization: Over 50% of surgeons advocate for active mobilization either immediately or as soon as possible 3
   • Continuous antibiotic irrigation may allow for outpatient management and earlier rehabilitation 4

Non-Infectious Flexor Tenosynovitis (Trigger Finger)

Non-infectious flexor tenosynovitis, commonly known as "trigger finger," can be effectively treated with less invasive approaches.

Management Algorithm for Non-Infectious Flexor Tenosynovitis

1. First-Line Treatment

   • NSAIDs as first-line drug treatment for pain management 5
   • Rest, physical therapy, and/or splinting 6

2. Second-Line Treatment

   • Local corticosteroid injection if first-line treatments fail
   • Highly effective: 61% resolution after a single injection
   • Nearly 90% success rate with repeated injections 6
   • Limit corticosteroid injections to 2-3 with 4-6 weeks between injections 5

3. Surgical Management

   • Consider if symptoms persist despite 3-6 months of well-managed conservative treatment
   • Indicated in approximately 12% of cases where injections fail or early recurrence occurs 6

Rehabilitation Protocol

For both types of flexor tenosynovitis, rehabilitation follows a progressive protocol:

1. Initial Phase (0-4 weeks)

   • Focus on pain control and protected range of motion 5
   • RICE protocol (Rest, Ice, Compression, Elevation) for pain and inflammation management

2. Intermediate Phase (4-8 weeks)

   • Progressive strengthening exercises 5
   • Gradual increase in resistance and load

3. Advanced Phase (8-12 weeks)

   • Sport-specific or occupation-specific training 5
   • Return to full activity when:
     • Complete resolution of pain during and after activity
     • Full range of motion compared to uninjured side
     • Strength symmetry >90% compared to uninjured side 5

Common Pitfalls and Caveats

1. Delayed Diagnosis

   • Failure to recognize Kanavel's signs can lead to delayed treatment and worse outcomes
   • Laboratory and imaging assessments are not typically diagnostic; clinical examination is key 1

2. Treatment Variations

   • There is substantial variation in management approaches, particularly regarding the need for, timing, and type of surgical intervention 3, 2
   • No standardized treatment algorithm exists for PFT, leading to inconsistent practices 2

3. Potential Complications

   • Despite prompt treatment, complication rates can be high, leading to impaired function or even digit amputation 2
   • Local adverse reactions to corticosteroid injections (pain, stiffness, ecchymosis, subcutaneous fat atrophy) are usually self-limited 6

4. Follow-up Imaging

   • If symptoms persist beyond 4-6 weeks, plain radiographs should be obtained
   • MRI without contrast is indicated if symptoms persist despite 6-8 weeks of conservative management 5