Infectious tenosynovitis: Difference between revisions
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*Microbiology | *Microbiology | ||
*"Clean trauma" - skin flora | *"Clean trauma" - skin flora | ||
* | *[[Diabetes mellitus]], bites - Polymicrobial (gram -, anerobes) | ||
*Puncture from plants - Fungal (sporotrichosis) | *Puncture from plants - Fungal (sporotrichosis) | ||
*Hematogenous spread | *Hematogenous spread | ||
| Line 27: | Line 27: | ||
**(4) Pain with passive extension of the digit (early sign) | **(4) Pain with passive extension of the digit (early sign) | ||
== | ==Evaluation== | ||
*Labs: CBC, ESR/CRP, pre-op labs (T+S, coags, Chem-10) | *Labs: CBC, ESR/CRP, pre-op labs (T+S, coags, Chem-10) | ||
*X-Ray | *X-Ray | ||
**Usually normal but helpful to | **Usually normal but helpful to rule out bony involvement, FB | ||
*Blood culture (if possible, obtain from synovial fluid) | *Blood culture (if possible, obtain from synovial fluid) | ||
== | ==Management== | ||
*Elevation of hand to help with swelling | *Elevation of hand to help with swelling | ||
**Monitor clinically for hand compartment syndrome | **Monitor clinically for hand compartment syndrome | ||
Latest revision as of 01:30, 10 May 2019
Background
- Infection of extensor tendons rarely results in loculated infections, but disruption of normal flexor tendon function can be dangerous as it may spread proximally involving the wrist/forearm (Parona space). It is an surgical/orthopedic emergency!
Etiology
- Trauma with direct inoculation
- Microbiology
- "Clean trauma" - skin flora
- Diabetes mellitus, bites - Polymicrobial (gram -, anerobes)
- Puncture from plants - Fungal (sporotrichosis)
- Hematogenous spread
- Microbiology
- Gonorrhea
- Look for vesiculopustular skin lesion, polyarthralgia
- Mycobacteria
- Contiguous spread
Clinical Manifestations
- 4 Kanavel signs:
- (1) Finger held in slight flexion
- (2) Fusiform swelling
- (3) Tenderness along the flexor tendon sheath (late sign)
- (4) Pain with passive extension of the digit (early sign)
Evaluation
- Labs: CBC, ESR/CRP, pre-op labs (T+S, coags, Chem-10)
- X-Ray
- Usually normal but helpful to rule out bony involvement, FB
- Blood culture (if possible, obtain from synovial fluid)
Management
- Elevation of hand to help with swelling
- Monitor clinically for hand compartment syndrome
- Surgery/Ortho consult for wash-out vs. debridement
Antibiotics
Treatment should cover S. aureus, Streptococcus, and MRSA
- Vancomycin 25-30 mg/kg IV loading dose then 15-20mg/kg IV q12hrs PLUS
- Levofloxacin 750 mg IV once daily (avoid in pediatrics) OR
- Ceftriaxone 1g IV daily
- If suspicious of Gonococcal infection then use Ceftriaxone 1g IV once daily AND Chlamydia coverage with
- Azithromycin 1g PO once OR
- Doxycycline 100mg PO twice daily
Animal Bites
Ampicillin/Sulbactam 3g (50mg/kg) IV four times daily
Pediatrics
- Ceftriaxone 100mg/kg IV once daily AND Metronidazole 7.5mg/kg IV four times daily OR
- Clindamycin 10mg/kg IV four times daily NA TMP/SMX 5mg/kg IV BID
- Ampicillin/Sulbactam 50 mg/kg IV four times daily
Treatment should include usual therapy listed above in addition to:
- Clarithromycin 500mg PO twice daily PLUS
- Ethambutol 15 mg/kg PO once daily OR
- Rifampin 600 mg PO once daily
AND consult infectious disease