Infectious and Inflammatory Flexor Tenosynovitis Workup

  • Author: Randle L Likes, DO; Chief Editor: Harris Gellman, MD   more...
 
Updated: Feb 17, 2012
 

Laboratory Studies

  • If infection is suggested, culture of the suppurative synovial fluid is mandatory prior to beginning definitive antimicrobial treatment.
    • These cultures should include aerobic, anaerobic, fungal, acid-fast bacilli (AFB), and atypical AFB samples.
    • In nonsuppurative conditions, synovial fluid may show nonbirefringent crystals (gout) or birefringent crystals (calcium pyrophosphate deposition disease [CPPD] or pseudogout).
  • CBC
    • WBC count may be elevated in the presence of proximal infection or systemic involvement. WBC count is not elevated in nonsuppurative conditions.
    • A left shift is frequently present in acute processes.
    • WBC count often is not elevated in immunocompromised patients.
  • Erythrocyte sedimentation rate (ESR)
    • Although nonspecific, this study typically is elevated in acute or chronic infections and may serve as a marker to follow resolution of an infection.
    • ESR may be elevated in cases of inflammatory FT as well.
    • ESR is not elevated in nonsuppurative conditions.
    • Coagulation studies are needed in anticoagulated patients or in patients with known or suspected bleeding diathesis. In severe infection in which systemic sepsis is a concern, disseminated intravascular coagulation (DIC), though quite rare, must be ruled out.
  • Obtain rheumatologic factor if rheumatoid arthritis (RA) is a consideration.
  • Obtain acid-fast bacilli and fungal cultures in patients with chronic or atypical presentation.
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Imaging Studies

  • Obtain standard anteroposterior and lateral radiographs to rule out bony involvement or foreign body.[36]
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Other Tests

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Diagnostic Procedures

  • Synovial biopsy for histopathologic examination is helpful in diagnosing granulomatous changes observed in Mycobacterium infections and cases of chronic processes.
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Histologic Findings

Synovial biopsy may reveal acute or chronic inflammatory changes. Gram stains may reveal bacteria. A higher index of suspicion should be present for chronic infections or atypical presentations. These histologic findings help confirm diagnosis of inflammatory arthropathy.

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Contributor Information and Disclosures
Author

Randle L Likes, DO  Consulting Staff, Department of Emergency Medicine, Gateway Medical Center

Randle L Likes, DO is a member of the following medical societies: American College of Emergency Physicians and American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Sean D Ghidella  MD, Staff, Puget Sound Orthopaedics

Sean D Ghidella is a member of the following medical societies: American Association for Hand Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Peter M Murray, MD  Professor of Orthopedic Surgery, Mayo Clinic College of Medicine; Director of Education, Mayo Foundation for Medical Education and Research, Jacksonville; Consultant, Department of Orthopedic Surgery, Mayo Clinic, Jacksonville; Consulting Staff, Nemours Children's Clinic and Wolfson's Children's Hospital

Peter M Murray, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, Florida Medical Association, Orthopaedic Research Society, and Society of Military Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Thomas R Hunt III, MD  John D Sherrill Professor and Director of Orthopedic Surgery, Director of Hand and Upper Extremity Fellowship, University of Alabama at Birmingham School of Medicine; Surgeon-in-Chief, UAB Highlands Hospital

Thomas R Hunt III, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, American Society for Surgery of the Hand, AO Foundation, Mid-America Orthopaedic Association, and Southern Orthopaedic Association

Disclosure: Tornier Royalty Independent contractor; Tornier Ownership interest None; Lippincott Royalty Independent contractor

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD  Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society

Disclosure: Nothing to disclose.

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Location of annular and cruciform pulleys on the volar finger
Flexor tendon sheaths and radial and ulnar bursae
Table. Michon Classification Scheme
Infection Stage Characteristic Findings Treatment
Stage IIncreased fluid in sheath, mainly a serous exudateCatheter irrigation
Stage IIPurulent fluid, granulomatous synoviumMinimal invasive drainage +/- indwelling catheter irrigation
Stage IIINecrosis of the tendon, pulleys, or tendon sheathExtensive open debridement and possible amputation
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