What is the appropriate management for suppurative tenosynovitis of a finger caused by a fishbone puncture at work, including surgical intervention, tetanus prophylaxis, and antimicrobial therapy?

Management of Suppurative Tenosynovitis from Fishbone Injury

Finger suppurative tenosynovitis from a fishbone puncture requires immediate surgical irrigation and debridement combined with broad-spectrum antibiotics covering both typical skin flora and atypical organisms, plus tetanus prophylaxis. 1, 2

Immediate Wound Management

Perform copious irrigation with running tap water or sterile saline until all visible debris is removed. 1 Do not use povidone-iodine or other antiseptic solutions—they offer no advantage over plain water or saline and may cause additional tissue damage. 1 Avoid aggressive debridement that enlarges the wound unnecessarily. 1

Surgical Intervention (Critical Priority)

Suppurative tenosynovitis requires urgent surgical drainage to prevent tendon necrosis. 2 Aggressive surgical management is particularly important in tenosynovitis because delayed treatment leads to irreversible tendon damage. 2

Two surgical approaches are effective:

• Closed continuous irrigation: Insert a catheter into the tendon sheath at the A1 pulley level and exit at the A5 pulley, then irrigate continuously with sterile saline mixed with lidocaine to allow pain-free immediate mobilization. 3
• Open debridement and drainage: Traditional approach for severe cases or when closed irrigation fails. 2, 3
• Vacuum sealing drainage technique: After thorough debridement, this method has shown excellent results with treatment duration of 7-14 days in most cases, though some require up to 28 days with multiple dressing changes. 4

Ultrasound can confirm the diagnosis preoperatively—sonographic evidence of both a swollen tendon AND fluid in the flexor sheath indicates surgical drainage is needed. 5 Patients with only tendon swelling but no fluid may respond to antibiotics alone. 5

Antimicrobial Therapy

Start empiric antibiotics immediately covering staphylococci, streptococci, AND atypical organisms associated with marine/aquatic injuries. 2

First-line antibiotic choice:

Amoxicillin-clavulanate is the preferred oral agent because it covers typical skin flora plus Pasteurella multocida and other organisms from animal/environmental sources. 1 However, fishbone injuries warrant broader coverage than typical animal bites.

Special considerations for fishbone injuries:

Fishbone punctures can introduce atypical mycobacteria (M. marinum, M. fortuitum, M. abscessus, M. chelonae) which commonly cause tenosynovitis of the hand after aquatic trauma. 6 While acute suppurative tenosynovitis is typically bacterial, consider atypical mycobacteria if:

• Infection develops slowly over weeks rather than days 6
• Initial antibiotic therapy fails 6
• Granulomatous inflammation is seen on pathology 6

Empiric coverage should include:

• Oral regimen: Amoxicillin-clavulanate PLUS consideration of doxycycline (which has activity against some atypical mycobacteria) 1, 6
• Penicillin-allergic patients: Fluoroquinolone (ciprofloxacin, levofloxacin, or moxifloxacin) plus metronidazole or clindamycin 1
• Intravenous options for severe infection: Ampicillin-sulbactam, piperacillin-tazobactam, or second-generation cephalosporin (cefoxitin) 1

Avoid first-generation cephalosporins, macrolides, and clindamycin monotherapy—these have inadequate coverage for the polymicrobial flora expected in this injury. 1

Duration of therapy:

• Uncomplicated tenosynovitis: 3-4 weeks of targeted antibiotics based on culture results 1
• With osteomyelitis: 4-6 weeks 1
• Adjust based on culture and sensitivity results from surgical drainage 2

Tetanus Prophylaxis (Mandatory)

Administer 0.5 mL tetanus toxoid intramuscularly immediately if vaccination status is outdated or unknown. 1 Give a booster if >5 years since last dose for this contaminated wound. 1

Wound Closure Strategy

Do NOT close the wound primarily. 1 Infected wounds and wounds presenting >8 hours after injury should never be sutured. 1 Leave the wound open to heal by secondary intention or delayed primary closure after infection resolves. 1

Post-Operative Management

Initiate immediate active and passive range of motion exercises postoperatively to mechanically debride tissue and prevent stiffness. 3 If using closed continuous irrigation with lidocaine, titrate the infusion to achieve pain-free motion. 3

Elevate the injured hand using a sling for outpatients or tubular stockinet attached to an IV pole for inpatients. 1

Follow-Up and Monitoring

Arrange follow-up within 24 hours by phone or office visit to assess for progression of infection. 1 Signs requiring immediate re-evaluation include:

• Increasing pain disproportionate to injury 1
• Redness, swelling, or foul-smelling drainage 1
• Fever 1
• Loss of finger motion 2

Culture and Pathogen Identification

Send all drainage fluid and tissue for aerobic, anaerobic, AND mycobacterial cultures. 6, 2 Tissue biopsy is more sensitive than fluid culture for recovering organisms. 6

Common pathogens in suppurative tenosynovitis include:

• Staphylococcus aureus and S. epidermidis (most common) 4, 2
• Streptococci 2
• Pasteurella multocida (from animal/environmental sources) 1, 2
• Atypical mycobacteria (M. marinum, M. fortuitum, M. abscessus, M. chelonae) particularly after aquatic trauma 6
• Gram-negative organisms (E. coli, Enterobacter, Klebsiella, Proteus, Acinetobacter) 4

Critical Pitfalls to Avoid

• Do not delay surgical drainage—tendon necrosis occurs rapidly and is irreversible 2
• Do not use inadequate antibiotic coverage—avoid cephalexin, macrolides, or clindamycin alone 1
• Do not close the wound primarily—this traps infection and worsens outcomes 1
• Do not forget tetanus prophylaxis—contaminated wounds require updated vaccination 1
• Do not overlook atypical mycobacteria—fishbone injuries in aquatic environments are high-risk 6
• Do not use antiseptic irrigation solutions—they provide no benefit over saline and may harm tissue 1

Occupational Injury Documentation

Document this as a workplace injury for workers' compensation purposes, including detailed mechanism (fishbone puncture), timing, and initial treatment. 1