Infectious tenosynovitis: Difference between revisions
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==Background== | ==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== | |||
==Etiology == | |||
* Trauma with direct inoculation | *Trauma with direct inoculation | ||
* 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 | ||
* Microbiology | *Microbiology | ||
* Gonorrhea | *Gonorrhea | ||
* Look for vesiculopustular skin lesion, polyarthralgia | *Look for vesiculopustular skin lesion, polyarthralgia | ||
* Mycobacteria | *Mycobacteria | ||
* Contiguous spread | *Contiguous spread | ||
==Clinical Manifestations== | ==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]]=== | |||
{{Infectious Tenosynovitis Antibiotics}} | |||
== | [[Category:Orthopedics]] | ||
* | |||
* | |||
* | |||
* Surgery consult for wash-out | |||
[[Category: |
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