Mr. K was also started on indomethacin (Indocin) 50 mg q.i.d. for acute gout and his furosemide was discon­tinued, pending resolution of the gout. Within 48 hours, Mr. K showed significant decreases in pain, erythema and swelling. 


5. Discussion


Flexor tenosynovitis is a disorder of the sheath, or lining, of each of the flexor tendons of the fingers. The sheath contains synovial fluid, which protects and lubricates the fingers, allowing for ease of flexion.1 When the sheath becomes inflamed, a patient will typically present with one or more of the Kanavel signs.1



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Flexor tenosynovitis can be inflammatory (secondary to diabetes, rheumatoid arthritis or overuse of the digit), but infectious flexor tenosynovitis is more common and often requires immediate intervention.3 If diagnosed within 24 hours of initial symptoms, it can be treated conservatively with antibiotics. However, lack of significant improvement after 12 hours demands surgical incision and drainage of the tendon sheath. 


Several underlying facts pointed toward inflammatory causes in Mr. K’s case: SLE is a chronic, autoimmune disease that causes systemic inflammation and tissue damage. There do exist cases of reported flexor tenosynovitis as a manifestation of SLE.4,5 Mr. K’s associated knee erythema and pain would also be consistent with a systemic inflammatory issue. 


Although the workup of Mr. K’s hand showed no signs of penetration into the tendon and no report of injury, bacterial infection cannot be overlooked. The elevated WBC and ESR counts indicate infection. 


Gouty flexor tenosynovitis, as an initial presentation of gout, is quite rare. Gout is a form of arthritis that is caused by an inflammatory reaction to urate crystals that build up in joints, bones and subcutaneous structures. The surrounding skin can become so inflamed that it can often be mistaken for cellulitis.6,7

Mr. K presented with a number of risk factors for gout; his alcohol use, acute renal insufficiency from his SLE medications and diuretic use for hypertension were all considered contributing factors.7

6. Summary


Recognizing flexor tenosynovitis is critical, as it is a potential orthopedic emergency. Patients with autoimmune diseases or diabetes may present with inflammatory tenosynovitis. Infectious causes must be ruled out when there is obvious trauma or penetration into the palmar aspect of the finger or hand.

A detailed history and physical examination are key to determining proper care. Flexor tenosynovitis is not suited for outpatient treatment. Providers need to refer patients to the nearest hand or orthopedic surgeon or ED for immediate evaluation and treatment.

Jennifer Snyder, CNP, practices at Riverside Methodist Hospital in Columbus, Ohio. She specializes in hand orthopedics. 


References


1. The Wheeless Text of Orthopaedics Infectious Flexor Tenosynovitis information page. Duke Orthopaedics Wheeless Text of Orthopaedics website.

2. Moore JR, Weiland AJ. “Gouty tenosynovitis in the hand.” J Hand Surg Am.1985;10:291-295. 


3. Aslam N, Lo S, McNab I. “Gouty flexor tenosynovitis mimicking 
infection: a case report emphasizing the value of ultrasound in diagnosis.” Acta Orthopaedica Belgica. 2004;70:368-370. 


4. CDC. Systemic Lupus Erythematosus information page. CDC website.

5. Tada Y, Sadakata M, Koarada S et al. “Flexor tenosynovitis of the hands as an initial manifestation of systemic lupus erythematosus.” Mod Rheum. 2000;10:173-175. 


6. Mayo Clinic Gout information page. Mayo Clinic website. 


7. Rothschild BM. Griffith’s 5-Minute Clinical Consultant. Philadelphia, Pa. Lippincott Williams & Wilkins; 2006:454-455. 


All electronic documents accessed on January 4, 2011.