What is the diagnosis and treatment for pyogenic flexor tenosynovitis?

From the Guidelines

Pyogenic flexor tenosynovitis requires immediate surgical drainage combined with antibiotic therapy to prevent tendon necrosis, adhesions, and permanent functional impairment of the hand. The condition presents with Kanavel's four cardinal signs: finger held in slight flexion, uniform swelling of the entire finger, tenderness along the flexor tendon sheath, and severe pain on passive extension of the finger.

Diagnosis and Treatment

• The diagnosis of pyogenic flexor tenosynovitis can be supported by imaging studies, with MRI being a useful modality for diagnosing infectious and noninfectious tenosynovitis in both the flexor and extensor wrist compartments 1.
• Treatment involves surgical intervention, including tendon sheath irrigation and debridement, with potential placement of an irrigation catheter for continuous postoperative irrigation.
• The recommended antibiotic regimen typically includes intravenous coverage for Staphylococcus aureus, Streptococcus species, and gram-negative organisms, such as vancomycin 15-20 mg/kg IV every 12 hours plus either piperacillin-tazobactam 3.375g IV every 6 hours or cefepime 2g IV every 8 hours.
• Following surgery, early protected range of motion exercises should begin to prevent adhesions.
• The duration of antibiotic therapy is typically 2-4 weeks, with transition to oral antibiotics based on culture results and clinical improvement, as suggested by guidelines for the treatment of skin and soft tissue infections 1.

Key Considerations

• Prompt diagnosis and treatment are crucial to prevent complications and improve outcomes in patients with pyogenic flexor tenosynovitis.
• The choice of antibiotic regimen should be guided by culture results and clinical judgment, with consideration of the potential for resistance and the need for broad-spectrum coverage.
• Surgical intervention should be performed by an experienced surgeon, with attention to detail and a focus on preserving tendon function and preventing adhesions.

From the Research

Definition and Overview

• Pyogenic flexor tenosynovitis (PFT) is a potentially devastating closed-space infection of the flexor tendon sheath of the hand that can result in considerable morbidity 2.
• It is an aggressive closed-space infection that can result in severe morbidity 3.

Treatment Options

• Management of PFT includes prompt administration of empirical intravenous antibiotics and often surgical treatment 2.
• Surgical treatment of pyogenic flexor tenosynovitis has been widely described, but the role of antibiotic therapy is inadequately understood 3.
• Use of antibiotics as a component of therapy resulted in improved range of motion outcomes 3.
• Catheter irrigation rather than open washout also resulted in improved range of motion outcomes 3.
• Oral postoperative antibiotic therapy with amoxicillin + clavulanic acid for 7-14 days appears to be effective, allowing for outpatient management 4.

Surgical Management

• Many utilize a combination of surgical decompression and sheath irrigation 2.
• Almost 50% of clinicians would proceed to surgical decompression and washout even in patients diagnosed early, increasing to 88% when treating a patient whose diagnosis was delayed 5.
• The majority of those advising surgery felt this should be within 24 hours 5.
• A two-incision technique with catheter irrigation is commonly used 5.

Antibiotic Therapy

• There is no consensus on the use of antibiotics in pyogenic flexor tenosynovitis 4.
• The duration of postoperative antibiotic therapy did not lead to any difference in healing rate 4.
• Treating for less than 7 days versus 7-14 days seemed to be associated with a higher risk of failure, although not statistically significant 4.
• Intravenous or intravenous followed by oral administration did not provide any benefit compared to an exclusively oral treatment 4.

Outcome and Prognosis

• Despite prompt treatment, complication rates can be high, leading to impaired function and even amputation of the affected digit 2.
• Early diagnosis and prompt treatment are required to preserve the digit and prevent morbidity and loss of hand function 6.
• Further research is needed to elucidate the role of local antibiotics and corticosteroids in treating this condition and potentially preventing the morbid outcomes that are currently seen 2.