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Suppurative Tenosynovitis

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Suppurative Tenosynovitis, Infective Tenosynovitis, Pyogenic Flexor Tenosynovitis, Purulent Tenosynovitis, Kanavel's Cardinal Signs

  • See Also
  1. Hand Infection
  2. Fight Bite
  • Definitions
  1. Suppurative Tenosynovitis
    1. Closed space Infection within hand flexor tendon sheath
  • Epidemiology
  1. Suppurative Tenosynovitis accounts for 3 to 9% of all Hand Infections
  • Pathophysiology
  1. MIcrobial infection within the flexor tendon sheath
  2. Synovial Fluid is an ideal medium for Bacterial growth
    1. Tendon sheaths have a poor vascular supply
    2. Synovial Fluid collection
  • Causes
  • Organisms
  1. Most common causative organisms (30 to 80% of cases)
    1. Staphylococcus aureus
    2. Streptococcus
  2. Other infections
    1. Gram Negative Bacteria (10% of responsible organisms)
    2. Disseminated Neisseria gonorrhoeae
    3. Disseminated candida albicans (Immunocompromised patients)
    4. Mixed oral anaerobic and aerobic Bacteria (Injection drug use)
  • Mechanisms
  1. Deep penetrating wound to the palmar surface of the hand or finger (most common)
  2. Blunt Hand Trauma
  3. Extension of felon
  4. Puncture Wound of finger
  5. High Pressure Injection Wounds
    1. Paint injection (most toxic!)
    2. Oil or grease injection
  6. Disseminated Infection (e.g. Neisseria gonorrhoeae)
  • Risk Factors
  1. Immunocompromised patients (e.g. HIV Infection)
  2. Worse outcomes with >5 years of Tobacco Abuse
    1. More serious infections, delayed Wound Healing
  • Signs
  1. Febrile and toxic appearing patient
  2. Kanavel's four cardinal signs
    1. Findings
      1. Finger is uniformly swollen (digital fusiform swelling)
      2. Finger held in slight flexion for comfort
      3. Course of inflamed sheath is markedly tender
      4. Passive finger extension causes intense pain
        1. Highly sensitive for flexor tendon infection
        2. Tender to percussion along the flexor tendon sheath
    2. Efficacy
      1. Test Sensitivity: 91 to 97%
      2. Test Specificity: 51 to 69%
      3. Kennedy (2017) Hand 12(6):585-90 +PMID: 28720000 [PubMed]
  • Differential Diagnosis
  1. Deep space abscess (localized tenderness)
  2. Felon
  3. Cellulitis
  4. Animal Bite
  5. Clenched-fist Injury (Fight Bite)
  6. Necrotizing Fasciitis
  7. Disseminated Candida albicans (Immunocompromised patients)
  8. Disseminated Neisseria gonorrhoeae
  9. Osteomyelitis
  10. Septic Joint
  • Labs
  1. Inflammatory markers
    1. White Blood Cell Count elevated
    2. Erythrocyte Sedimentation Rate (ESR) elevated
    3. C-Reactive Protein (CRP) elevated
    4. Efficacy
      1. High Test Specificity 100% and Positive Predictive Value 100% for surgical management indications
      2. However, very low Test Sensitivity 39 to 76%, and low Negative Predictive Value 4 to 13%
      3. Bishop (2013) J Hand Surg Am 38(11): 2208-11 [PubMed]
  • Imaging
  1. Imaging is optional and not fully diagnostic for Suppurative Tenosynovitis
    1. Although imaging may offer supportive evidence, flexor tenosynovitis is a clinical diagnosis
  2. Ultrasound
    1. May show tendon effusion within sheath or abscess
    2. Efficacy in Suppurative Tenosynovitis
      1. Test Sensitivity 95%
      2. Test Specificity 74%
      3. Negative Predictive Value 95%
      4. Jardin (2018) Hand Surg Rehabil 37(2): 95-8 [PubMed]
  3. XRay
    1. May demonstrate radiopaque retained soft tissue foreign body
  4. MRI Hand
    1. Most sensitive imaging modality for clear definition of involved structures
  • Management
  1. Early recognition and treatment is critical
  2. Consult hand surgery urgently (within 24 to 72 hours)
  3. Hand surgery indications: No improvement in 24 hours of Antibiotics
    1. Minimal incision with catheter irrigation of tendon sheath (preferred) OR
    2. Wide Incision and Drainage
      1. May be indicated in High Pressure Injection Wound
  4. Extremity elevation and Splinting
  5. Remove rings from fingers
  6. Tetanus Prophylaxis
  7. Management based on Kanavel signs
    1. Kanavel Signs 3 to 4
      1. Intravenous Antibiotics and urgent surgical evaluation for intervention
    2. Kanavel Signs 2
      1. Intravenous Antibiotics, hospital observation and surgical Consultation
    3. Kanavel Signs 0 to 1 (typically early presentation in first 48 hours)
      1. Initial home management on oral Antibiotics with 24 hour follow-up
      2. Outpatient Antibiotics and close interval follow-up may be continued if patient is improving
        1. However, implement IV Antibiotics and urgent surgical evaluation for worsening
  8. Initial ParenteralAntibiotics
    1. First-line Parenteral coverage for MRSA
      1. Vancomycin
      2. Daptomycin
      3. Linezolid
      4. Televancin
      5. Clindamycin (depending on local sensitivities to MRSA)
    2. Injection drug use (polymicrobial coverage as well as MRSA)
      1. Vancomycin AND
      2. Piperacillin/Tazobactam (Zosyn)
    3. Disseminated Neisseria gonorrhoeae suspected
      1. Ceftriaxone (Rocephin)
    4. Older Antibiotic regimens that may be considered in more mild, borderline cases (Streptococcus, Staphylococcus)
      1. Cefazolin (Ancef) or
      2. Ampicillin-sulbactam (Unasyn) or
  9. Later oral Antibiotics for home
    1. Continue for 5 to 14 days after discharge
  10. Following initial surgical and Antibiotics management
    1. Occupational therapy (hand therapy) Consultation
  • Complications
  • Acute
  1. Contiguous spread of Infection throughout hand
    1. Proximal extension of deep space infection up the arm may also occur
  2. Associated with rapid increase in pressure
    1. Pus accumulation
    2. May obliterate tendon blood supply
    3. Results in tendon necrosis, function loss, and ultimately tendon rupture
  • Complications
  • Chronic
  1. Chronic finger stiffness and reduced function
  2. Finger Amputation due to worsening or recurrent infection
  • References
  1. Hori (2015) Crit Dec Emerg Med 29(3): 2-7
  2. McGowan (2023) Crit Dec Emerg Med 37(4): 18-9
  3. Boles (1998) Hand Clin 14:567-78 [PubMed]
  4. Clark (2003) Am Fam Physician 68:2167-76 [PubMed]
  5. Mamane (2018) J Orthop 15(2): 701-6 [PubMed]
  6. Rerucha (2019) Am Fam Physician 99(4):228-36 [PubMed]