Management of Suppurative Tenosynovitis of the Finger
Suppurative tenosynovitis requires urgent surgical drainage combined with intravenous antibiotics to prevent tendon necrosis and permanent functional loss. 1
Immediate Surgical Management
Aggressive surgical intervention is the cornerstone of treatment and should not be delayed. 1 The infection occurs in a closed space where purulent fluid under pressure rapidly compromises tendon blood supply, leading to irreversible necrosis within hours to days.
Surgical Options
Two equally effective surgical approaches exist:
- Open drainage (OD) through a single or multiple incisions with direct visualization and debridement 2
- Closed catheter irrigation (CCI) of the tendon sheath with continuous or intermittent flushing 2
Both techniques produce similar outcomes for pain control, functional recovery, and reoperation rates when performed promptly. 2 The choice depends on surgeon preference and local expertise, as no superiority has been demonstrated between methods.
Vacuum-Assisted Closure
- Vacuum sealing drainage (VSD) after thorough debridement shows excellent results, particularly for complex cases 3
- Treatment duration typically ranges 7-14 days with dressing changes every 7 days 3
- This technique effectively controls infection and promotes healing in both acute and chronic suppurative tenosynovitis 3
Antibiotic Therapy
Empiric Coverage
Initiate intravenous antibiotics immediately targeting staphylococci and streptococci. 1 The most common pathogens are Staphylococcus aureus and Staphylococcus epidermidis. 3
Specific Regimens
For standard community-acquired infections without specific risk factors:
- Intravenous beta-lactam/beta-lactamase combinations (ampicillin-sulbactam, piperacillin-tazobactam) provide broad coverage 4
- Second-generation cephalosporins (cefoxitin) or carbapenems (ertapenem, imipenem, meropenem) are alternatives 4
Special Considerations for Bite Wounds
If tenosynovitis results from animal bites:
- Amoxicillin-clavulanate covers Pasteurella multocida and anaerobes 4
- Avoid first-generation cephalosporins, penicillinase-resistant penicillins, macrolides, and clindamycin as monotherapy—these have poor activity against P. multocida 4
Duration
- Standard tenosynovitis: Continue antibiotics for 3-4 weeks 4
- Associated osteomyelitis: Extend treatment to 4-6 weeks 4
Diagnostic Confirmation
Ultrasound is highly valuable for early diagnosis before surgical exploration. 5 Sonographic findings that indicate surgical drainage is needed:
- Fluid within the flexor tendon sheath (highly specific for purulent infection) 5
- Swollen, thickened tendon 5
Patients with only tendon swelling but no fluid may respond to antibiotics alone, though close monitoring is essential. 5
Prognostic Factors
Poor Outcome Predictors
Several factors significantly worsen functional outcomes and require more aggressive management:
- Delayed time to antibiotic administration correlates with worse function 2
- Staphylococcus aureus infection produces inferior outcomes compared to other organisms 2
- Smoking prolongs required antibiotic duration and impairs healing 2
Expected Recovery
With prompt surgical drainage and appropriate antibiotics, most patients achieve full recovery. 5 However, any delay in treatment risks tendon necrosis requiring tendon excision and permanent functional impairment. 3
Critical Pitfalls to Avoid
- Never delay surgery for antibiotic trial alone—the closed-space nature of tenosynovitis makes medical management insufficient 1
- Do not underestimate hand infections—complications including tendon necrosis, septic arthritis, and osteomyelitis develop rapidly 4
- Ensure tetanus prophylaxis is current for all traumatic cases 4
- Elevate the affected hand continuously during initial treatment to accelerate healing 4
- Plan for follow-up within 24 hours after initiating treatment to assess response 4