What is the treatment for infectious synovitis of the hand or wrist?

Treatment of Infectious Synovitis of the Hand/Wrist

The treatment of infectious synovitis of the hand or wrist requires prompt antimicrobial therapy combined with appropriate surgical intervention, with parenteral antibiotics for 2-4 weeks for septic arthritis and 3-4 weeks for synovitis, followed by oral antibiotics to complete the course. 1

Initial Assessment and Diagnosis

• Obtain synovial fluid samples through aspiration for culture and Gram stain
• Order blood cultures, complete blood count, C-reactive protein, and erythrocyte sedimentation rate
• Consider imaging (X-ray, MRI) to assess joint damage and identify potential abscesses
• Differentiate from non-infectious causes (gout, rheumatoid arthritis)

Antimicrobial Therapy

Empiric Antibiotic Selection

1. Intravenous options (first-line):

   • Beta-lactam/beta-lactamase combinations (ampicillin-sulbactam)
   • Piperacillin/tazobactam
   • Second-generation cephalosporins (cefoxitin)
   • Carbapenems (ertapenem, imipenem, meropenem) 1

2. Oral options (after initial IV therapy):

   • Amoxicillin-clavulanate (studied and recommended for outpatient therapy)
   • Alternative oral agents: doxycycline, fluoroquinolones with metronidazole 1

3. Avoid as monotherapy due to poor coverage:

   • First-generation cephalosporins (cephalexin)
   • Penicillinase-resistant penicillins (dicloxacillin)
   • Macrolides (erythromycin)
   • Clindamycin 1

Duration of Therapy

• Septic arthritis: 4 weeks total
• Synovitis: 3-4 weeks total 1
• Initial parenteral therapy: Most patients can receive <1 week of parenteral antimicrobial treatment followed by 2-3 weeks of oral therapy when combined with adequate surgical debridement 2

Surgical Management

Indications for Surgery

• Most cases of infectious synovitis require surgical intervention
• Exceptions: Some early cases may respond to conservative management with antibiotics, immobilization, and elevation 3

Surgical Options

1. Open arthrotomy with debridement (most common, 82.5% of cases) 2
2. Arthroscopic debridement (less invasive option, 5% of cases) 2
3. Aspiration alone (for early or mild cases, 12.5% of cases) 2
4. Synovectomy (for specific cases like tuberculous synovitis) 4

Adjunctive Measures

1. Immobilization and elevation

   • Immobilize the affected joint with appropriate splinting
   • Elevate the hand to reduce swelling 3

2. Pain management

   • Acetaminophen for mild pain
   • NSAIDs if not contraindicated
   • Consider topical NSAIDs as first-line for pain management 5

3. Rehabilitation

   • Begin range of motion exercises once acute inflammation subsides
   • Strengthening exercises to stabilize the joint 5

Special Considerations

Mycobacterial Infections

• For suspected tuberculous synovitis, consider:
  • Radical synovectomy combined with anti-tuberculous therapy
  • Extended antimicrobial treatment (typically 6-12 months) 4

Chronic or Subacute Infections

• Higher risk for finger amputation
• May require more aggressive surgical debridement
• Consider atypical organisms (mycobacteria, fungi) 2

Monitoring and Follow-up

• Schedule follow-up within 24 hours for outpatients
• Monitor for progression of infection despite therapy
• Consider hospitalization if infection progresses despite good antimicrobial and ancillary therapy 1
• Ensure tetanus prophylaxis is current 1

Complications to Watch For

• Septic arthritis
• Osteomyelitis
• Subcutaneous abscess formation
• Tendonitis
• Bacteremia (rare) 1

Treatment Algorithm

1. Early presentation (Kanavel's signs present <48 hours):

   • Consider trial of IV antibiotics, immobilization, and elevation
   • Proceed to surgical intervention if no improvement within 24-48 hours

2. Established infection (>48 hours or severe presentation):

   • Immediate surgical debridement
   • IV antibiotics for 3-7 days
   • Transition to oral antibiotics to complete 3-4 week course

3. Special cases (tuberculous, fungal, or atypical infections):

   • Extended antimicrobial therapy
   • Consider radical synovectomy
   • Consult infectious disease specialist

Remember that hand infections can progress rapidly and lead to significant morbidity if not treated promptly and appropriately. Early and aggressive intervention is key to preserving hand function.