Infectious tenosynovitis

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 AND TMP/SMX 5mg/kg IV BID
• Ampicillin/Sulbactam 50 mg/kg IV four times daily

Mycobacteria related

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