Flexor Tenosynovitis with Brit Long

Matthew DeLaney, MD, FACEP, FAAEM and Brit Long, MD

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The summary below is from an episode of ERcast: Clinical Perspectives

Pyogenic flexor tenosynovitis is a closed-space hand infection that can rapidly threaten tendon viability, finger motion, and even systemic stability. The diagnosis is clinical: Kanavel signs are helpful but often incomplete, and normal inflammatory markers do not rule it out.

Flexor Tenosynovitis Diagnosis and Treatment

Closed-space infection pattern: FTS is an infection of the flexor tendon sheath where rising compartment pressure can compromise digital blood flow, driving tendon necrosis, adhesions, and permanent loss of motion.
Incomplete Kanavel presentation: Any Kanavel sign should raise concern because fewer than 54% of patients have all four findings, and roughly half present with only one or two signs, a nuance we get into in the episode.
Most useful exam clues: Pain with passive extension is often the earliest Kanavel sign, and tenderness should track along the volar tendon sheath rather than the dorsal finger.
Normal labs do not exclude: WBC, ESR, and CRP are often abnormal but nonspecific, so normal values should not reassure you away from a clinical diagnosis of flexor tenosynovitis.
Imaging as adjunct only: X-ray helps look for foreign body or osteomyelitis, and POCUS may show sheath edema or thickening, but neither imaging nor CT reliably rules out FTS.
Early admission and antibiotics: All suspected cases need hand-surgery or orthopedic involvement, IV antibiotics, elevation, and admission for close monitoring; some early cases may avoid the OR if they improve promptly.

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References:

Mehta P, Thoppil J, Koyfman A, Long B. High risk and low prevalence diseases: Flexor tenosynovitis. Am J Emerg Med. 2024 Mar;77:132-138. PMID: 38147700
Brusalis C, Thibaudeau S, Carrigan R, Lin I, Chang B, Shah A. Clinical Characteristics of Pyogenic Flexor Tenosynovitis in Pediatric Patients. The Journal of Hand Surgery. 2017;42(5):338.E1-338.E5. PMID: 28341068
Latario L, Abeler J, Clegg S, Thurber L, Igiesuorobo O, Jones M. Antibiotics Versus Surgery in Treatment of Early Flexor Tenosynovitis. Hand (N Y). 2023 Jul;18(5):804-810. PMID: 35081807
Giladi AM, Malay S, Chung KC. A systematic review of the management of acute pyogenic flexor tenosynovitis. J Hand Surg Eur Vol. 2015 Sep;40(7):720-8. PMID: 25670687

Faculty

Matthew DeLaney, MD, FACEP, FAAEM
Dr. Matthew DeLaney is an emergency medicine physician and educator based in Birmingham, Alabama. A native of Mobile, he earned his medical degree from the University of South Alabama and completed his emergency medicine residency at Maine Medical Center.Dr. DeLaney has experience in both community and academic emergency medicine and is known for his commitment to teaching and medical education. He lives in Birmingham with his wife, Erin, who is also a physician, and their two daughters.
Brit Long, MD
Dr. Brit Long is a Professor of Emergency Medicine at the University of Virginia and an emergency medicine physician with experience in both a community ED and at a military academic center ED. He is the Clinical Editor-in-Chief of emDOCs.His professional interests include medical education, evidence-based medicine, and the FOAMed movement. Outside of work, he enjoys spending time with his wife and two daughters