Infectious tenosynovitis: Difference between revisions
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* 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! | * 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== | ||
Revision as of 16:47, 5 July 2016
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
- DM, 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)
Diagnosis
- Labs: CBC, ESR/CRP, pre-op labs (T+S, coags, Chem-10)
- X-Ray
- Usually normal but helpful to r/o bony involvement, FB
- Blood culture (if possible, obtain from synovial fluid)
Treatment
- 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