Flexor Tenosynovitis

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    Flexor Tenosynovitis

    Tenosynovitis = inflammation of a tendon and its sheath.  Most acute cases of flexor tenosynovitis (FT) are infectious but may also be secondary to inflammation from noninfectious cause (e.g. diabetes, overuse, arthritis)

    Infectious tenosynovitis

    May be result of trauma with direct inoculation (eg, laceration, puncture or bite), contiguous spread from infected adjacent soft tissues, or hematogenous spread. The most common pathogens in the setting of trauma are skin flora (eg, Staphylococcus aureus and streptococci). Pathogens associated with hematogenous spread include N. gonorrhoeae and mycobacteria.

    Physical examination reveals Kanavel signs of flexor tendon sheath infection:

    • Finger held in slight flexion
    • Fusiform swelling
    • Tenderness along the flexor tendon sheath
    • Pain with passive extension of the digit

    Clinical features of gonococcal tenosynovitis include:

    • Erythema, tenderness to palpation, and painful range of motion (ROM) of the involved tendon(s)
    • Fever – A common sign
    • Dermatitis – Also a common sign; it occurs in approximately two thirds of disseminated gonococcal infections; it is characterized by hemorrhagic macules or papules on the distal extremities or trunk

    Inflammatory flexor tenosynovitis

    • Usually the result of an underlying disease process
    • Presentation is indolent but progressive if therapy is not initiated
    • Similar findings to those found in infectious FT eventually present
    • Swelling is the most common initial finding
    • Hallmark is a difference in active, versus passive, flexion
    • As the tissue expands and impingement occurs, pain and restricted motion ensue

    Diagnosis

    Diagnosis of tenosynovitis is confirmed by microbiological and histopathological evaluation: culture of the suppurative synovial fluid, diagnostic arthrocentesis is indicated if joint effusion is present (may have septic arthritis also, especially with gonococcal infection).

    Management

    Surgical intervention and antibiotic therapy.  Generally, early infection should be managed with tendon sheath irrigation and drainage, with or without debridement. Advanced infection should be managed with debridement of the tendon sheaths and surrounding necrotic tissue.

    In certain circumstances, an acute presentation within the first 24 hours of infection development may initially be medically managed.  Prompt improvement of symptoms and physical findings must follow within 12 hours; otherwise, surgical intervention is necessary.

     

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