Flexor Tenosynovitis

Flexor tenosynovitis is a surgical emergency that must be diagnosed promptly by the examining physician and managed aggressively by both the emergency physician and the hand surgeon. Failure to accurately diagnose and manage a flexor tenosynovitis will lead to loss of function of the digit and eventually loss of function of the entire hand. Diagnosis is made by recognizing the classic clinical findings described by Kanavel. The four cardinal signs are tenderness over the flexor tendon sheath, symmetric swelling of the finger, pain with passive extension, and a flexed posture of the involved digit at rest.

The infection usually is associated with penetrating trauma of the affected area, although the patient may be unaware of this injury. Staphylococcus is the most common bacteria isolated; however, infections often harbor anaerobes and are routinely polymicrobial in origin. -^H, One should suspect disseminated Neisseria gonorrhoeae in any patient who has a recent history consistent with a sexually transmitted disease.

The emergency physician should initiate treatment with parenteral antibiotics. This should include a b-lactamase inhibitor or first-generation cephalosporin and penicillin. Vancomycin should be considered for patients who abuse drugs intravenously because they may harbor methicillin-resistant S. aureus (MRSA).1 Any spontaneous exudate from the infection should be sent for Gram stain and culture with sensitivities.

The hand should be immobilized and elevated, and a hand surgeon should be consulted on an emergent basis. If the infection is identified early in its course, conservative therapy may be indicated initially. The patient would then be treated with parenteral antibiotics, immobilization, elevation, and reevaluation within 24 h. The decision to manage the patient without operative intervention must be made with involvement of the hand surgeon.

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