Raiyyan Tahsan

Raiyyan Tahsan
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TC(1038).(05).Orthopedics Case No 116:- Tenosynovitis

Tenosynovitis — বাংলা Clinical Note

গুরুত্বপূর্ণ সতর্কতা: আঙুলে তীব্র ব্যথা, ফোলা, লাল/গরম, জ্বর, ক্ষত/কাটা/কাঁটার ইতিহাস, আঙুল বাঁকা হয়ে থাকা বা সোজা করলে প্রচণ্ড ব্যথা থাকলে pyogenic flexor tenosynovitis সন্দেহ করতে হবে—এটি hand-surgery emergency। শুধুমাত্র analgesic দিয়ে delay করা যাবে না। Infectious flexor tenosynovitis–এ diagnosis Kanavel signs দিয়ে সন্দেহ করা হয় এবং treatment সাধারণত surgical drainage + antibiotics।

1. Definition / সংজ্ঞা

Tenosynovitis হলো tendon-এর চারপাশের synovial sheath বা tendon sheath-এর inflammation। এতে sheath ফুলে যায়, tendon smoothly glide করতে পারে না, ফলে pain, swelling, movement restriction, clicking/locking হয়। Non-infective ক্ষেত্রে rest, splinting ও NSAID সাধারণত first-line; প্রয়োজন হলে local corticosteroid injection বা surgery লাগে।

2. Causes / Etiology — কারণগুলো

A. Mechanical / Overuse

  • একই movement বারবার করা—typing, mobile use, gaming, sewing, writing, lifting।
  • Wrist/thumb repetitive abduction–extension → De Quervain tenosynovitis।
  • Finger flexor tendon sheath thickening → Trigger finger / stenosing tenosynovitis।

B. Trauma / Injury

  • হাত/আঙুলে কাটা, puncture wound, thorn/fish-bone/needle injury।
  • Minor penetrating injury থেকেও deep tendon sheath infection হতে পারে।

C. Infection

  • সবচেয়ে গুরুত্বপূর্ণ organism: Staphylococcus aureus, Streptococcus spp.
  • Bite wound হলে polymicrobial organism।
  • Disseminated gonococcal infection-এ tenosynovitis হতে পারে।
  • Infectious flexor tenosynovitis হলো closed-space infection—delay হলে tendon necrosis, stiffness, deformity, even amputation হতে পারে।

D. Inflammatory / Systemic disease

  • Rheumatoid arthritis
  • Psoriatic arthritis
  • Gout / pseudogout
  • Diabetes mellitus
  • Hypothyroidism
  • Chronic kidney disease / dialysis patients

E. Pregnancy / Postpartum

  • Postpartum mother-দের De Quervain বেশি দেখা যায়, baby lifting ও hormonal fluid retention এর কারণে।

3. Symptoms / Clinical Features — লক্ষণগুলো

Common symptoms

  • Tendon line বরাবর ব্যথা।
  • Local swelling বা ফুলে যাওয়া।
  • Movement করলে ব্যথা বাড়ে।
  • Tenderness—চাপ দিলে ব্যথা।
  • Stiffness—বিশেষ করে সকালে বা কাজের পর।
  • Crepitus / rubbing sensation—tendon নড়লে ঘষাঘষির অনুভূতি।
  • Weak grip / কাজ করতে অসুবিধা।

De Quervain Tenosynovitis

  • Wrist-এর thumb side/radial styloid region-এ pain।
  • Thumb নড়ালে, baby উঠালে, bottle খুললে, কাপড় নিংড়ালে pain বাড়ে।
  • Finkelstein/Eichhoff test positive হতে পারে।
  • Local swelling over first dorsal compartment।

Trigger finger / Stenosing tenosynovitis

  • Finger বাঁকালে আটকে যায় বা click করে।
  • সকালে finger locked অবস্থায় থাকতে পারে।
  • A1 pulley area-তে tender nodule।
  • Diabetes/RA patient-দের বেশি দেখা যায়।

Infective / Pyogenic flexor tenosynovitis

Kanavel signs:

  • Finger slight flexed position-এ থাকে।
  • Flexor tendon sheath বরাবর tenderness।
  • Fusiform swelling—পুরো আঙুল sausage-like ফুলে যায়।
  • Passive extension করলে severe pain।
    Kanavel signs PFT ধরতে sensitive, কিন্তু individual sign-এর specificity কম—clinical context গুরুত্বপূর্ণ।

4. Clinical Diagnosis — কীভাবে clinically diagnosis করবেন

History

  • Pain onset: acute না chronic?
  • Repetitive activity/occupation?
  • Trauma, bite, puncture wound?
  • Fever, redness, discharge?
  • Diabetes, RA, gout, immunosuppression?
  • Pregnancy/postpartum history?
  • Previous steroid injection বা surgery?

Examination

  • Site-specific tenderness: radial styloid, A1 pulley, flexor sheath।
  • ROM: active/passive movement painful কিনা।
  • Neurovascular status: capillary refill, sensation, pulses।
  • Special tests:
    • De Quervain: Finkelstein test, Eichhoff test, WHAT test।
    • Trigger finger: active flexion-extension এ locking/clicking, A1 pulley tenderness।
    • Infective flexor: Kanavel 4 signs।
  • Red flags: fever, rapidly progressive swelling, severe pain, immunocompromised, bite wound।

5. Investigations — specificভাবে কী কী করবেন

Non-infective suspected হলে

  • Usually clinical diagnosis enough।
  • Ultrasound MSK: tendon sheath thickening, fluid, hyperemia, septation; injection guidance।
  • X-ray: fracture, foreign body, calcification, arthritis exclude করতে।
  • MRI: diagnosis unclear, deep infection, mass, occult pathology suspected হলে।

Infective suspected হলে

  • CBC with differential।
  • CRP, ESR।
  • Blood culture—fever/sepsis থাকলে।
  • Wound/pus culture and sensitivity—surgical drainage করলে sample পাঠাতে হবে।
  • X-ray hand/wrist—foreign body, gas, osteomyelitis suspicion।
  • Ultrasound—fluid collection/tendon sheath effusion।
  • MRI—deep space infection/osteomyelitis সন্দেহ হলে।
  • RBS/HbA1c—diabetes screen/control।
  • Renal function, LFT—NSAID/antibiotic planning এর আগে।

Systemic inflammatory cause suspected হলে

  • RF, anti-CCP, ANA as indicated।
  • Serum uric acid—gout suspicion।
  • TSH—hypothyroidism suspicion।
  • Rheumatology referral if persistent/polyarticular.

6. Complications — রোগের জটিলতা

  • Chronic pain: inflammation দীর্ঘদিন থাকলে pain sensitization হতে পারে।
  • Stiffness and reduced ROM: tendon sheath thick হয়ে tendon glide কমে যায়।
  • Triggering/locking: tendon sheath narrowing হলে finger আটকে যায়।
  • Adhesion formation: infection বা prolonged inflammation শেষে tendon sheath ও tendon লেগে যেতে পারে।
  • Tendon rupture: uncontrolled infection, repeated steroid injection, wrong intratendinous injection।
  • Abscess / deep hand-space infection: infective case delay হলে।
  • Tendon necrosis: pyogenic flexor tenosynovitis untreated থাকলে।
  • Deformity / loss of hand function: late presentation বা inadequate rehab।
  • Amputation risk: severe infection, diabetes, immunosuppression, delayed drainage।

7. Treatment Management — Bangladesh prescription-oriented

A. General non-drug management

  • Pain-provoking activity ২–৪ সপ্তাহ কমানো।
  • Thumb/wrist/finger splint:
    • De Quervain: thumb spica splint।
    • Trigger finger: finger extension splint/night splint।
  • Ice pack ১০–১৫ মিনিট, দিনে ২–৩ বার।
  • Ergonomic correction।
  • Physiotherapy/hand therapy:
    • tendon-gliding exercise,
    • gentle stretching,
    • strengthening after acute pain improves।
  • De Quervain-এ evidence অনুযায়ী local corticosteroid injection + thumb spica immobilization ৩–৪ সপ্তাহ first-line হিসেবে ভালো ফল দেয়।

8. Pharmacological Drugs — dose, duration, side effect, interaction, Bangladesh brand

নিচের dose adult usual dose। CKD, liver disease, peptic ulcer, pregnancy, lactation, anticoagulant use, elderly, diabetes, immunosuppression থাকলে dose/choice adjust করতে হবে।

1) Paracetamol

  • Generic name: Paracetamol / Acetaminophen
  • Therapeutic category: Analgesic, antipyretic
  • Pharmacological class: Para-aminophenol derivative
  • কেন use হয়: Pain control; inflammation কমায় না, কিন্তু NSAID contraindicated হলে safer analgesic।
  • Dose: 500–1000 mg PO every 6–8 hours PRN; max 3 g/day safer limit, selected adults 4 g/day পর্যন্ত।
  • Duration: 3–5 days PRN।
  • Side effects: Nausea, rash; overdose → severe hepatotoxicity।
  • Interactions: Alcohol, chronic liver disease, warfarin with prolonged high-dose use।
  • Bangladesh available brands: Napa 500 mg, Ace 500 mg, Fast 500 mg, Reset 500 mg, Xpa 500 mg—MedEx এ paracetamol 500 mg brands হিসেবে listed।

2) Ibuprofen

  • Generic name: Ibuprofen
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; propionic acid derivative; non-selective COX inhibitor
  • কেন use হয়: Pain + inflammation কমাতে mild–moderate non-infective tenosynovitis।
  • Dose: 400 mg PO 8 hourly after food।
  • Duration: 3–5 days; prolonged use avoid।
  • Side effects: Dyspepsia, gastritis, GI bleed, renal impairment, BP rise, edema, bronchospasm in aspirin-sensitive asthma।
  • Interactions: Warfarin/DOAC, aspirin, steroid, SSRI, ACEi/ARB + diuretic, lithium, methotrexate।
  • Bangladesh brands: Profen 400 mg; MedEx Profen 400 mg page-এ pain/inflammation indications listed।

3) Naproxen

  • Generic name: Naproxen sodium
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; propionic acid derivative
  • কেন use হয়: Longer acting NSAID—wrist/thumb tenosynovitis pain + inflammation।
  • Dose: 250–500 mg PO twice daily after food।
  • Duration: 5–7 days; GI/renal risk থাকলে কম দিন।
  • Side effects: Gastric irritation, GI bleeding, renal dysfunction, edema, hypertension।
  • Interactions: Anticoagulants, antiplatelets, steroids, ACEi/ARB, diuretics, lithium, methotrexate।
  • Bangladesh brands: Naprox 500 mg, Naproxen 500 mg, Naproxin 250/500 mg, Napgin 500 mg, Napier 500 mg; MedEx brand listে these naproxen brands are listed।

4) Aceclofenac

  • Generic name: Aceclofenac
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; phenylacetic acid derivative
  • কেন use হয়: Bangladesh prescription-এ musculoskeletal pain/inflammation control-এর জন্য commonly used।
  • Dose: 100 mg PO twice daily after food।
  • Duration: 3–7 days।
  • Side effects: Dyspepsia, nausea, abdominal pain, GI ulcer/bleeding, renal impairment, liver enzyme rise।
  • Interactions: Anticoagulant/antiplatelet, steroid, SSRI, ACEi/ARB, diuretic, lithium, methotrexate।
  • Bangladesh brands: Aceclofenac 100 mg, Aceclora 100 mg, Acedol 100 mg, Acefenac 100 mg, Labenac 100 mg, Orcenac 100 mg—MedEx listed।

5) Diclofenac

  • Generic name: Diclofenac sodium / potassium
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; phenylacetic acid derivative
  • কেন use হয়: Acute inflammatory pain কমাতে; short course preferable।
  • Dose: 50 mg PO 8–12 hourly after food; max 150 mg/day।
  • Duration: 3–5 days।
  • Side effects: Gastritis, GI bleed, renal injury, edema, BP rise, hepatic enzyme elevation; CV risk relatively higher।
  • Interactions: Warfarin/DOAC, aspirin, steroid, SSRI, ACEi/ARB, diuretic, lithium, methotrexate।
  • Bangladesh brands: Diclofen 50 mg, Diclo 50 mg, Clofenac 50 mg, A-Fenac 50 mg, Diclofenac 50 mg; MedEx lists these diclofenac preparations and adult max daily dose 150 mg।

6) Etoricoxib

  • Generic name: Etoricoxib
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: Selective COX-2 inhibitor NSAID
  • কেন use হয়: NSAID দরকার কিন্তু GI intolerance তুলনামূলক বেশি হলে selected patient-এ; CV/HTN risk assess করতে হবে।
  • Dose: 60 mg PO once daily; severe acute pain-এ 90 mg OD short course specialist discretion।
  • Duration: 3–7 days।
  • Side effects: Hypertension, edema, dyspepsia, renal impairment, cardiovascular thrombotic risk।
  • Interactions: Warfarin, ACEi/ARB, diuretics, lithium, methotrexate।
  • Bangladesh brands: Etorix 60/90/120 mg, Etoshine 60/90/120 mg, Etosis 90/120 mg, Eto 60/90/120 mg, Etocox 60/90 mg, Etonil 60/90/120 mg—MedEx listed।

7) PPI gastroprotection with NSAID

Omeprazole / Esomeprazole / Pantoprazole

  • Generic name: Omeprazole / Esomeprazole / Pantoprazole
  • Therapeutic category: Anti-ulcerant, gastroprotective
  • Pharmacological class: Proton pump inhibitor
  • কেন use হয়: NSAID-induced gastritis/ulcer risk কমাতে; elderly, ulcer history, anticoagulant/steroid use-এ বেশি দরকার।
  • Dose:
    • Omeprazole 20 mg PO OD before breakfast, or
    • Esomeprazole 20 mg PO OD, or
    • Pantoprazole 20–40 mg PO OD।
  • Duration: NSAID course চলাকালীন; high-risk হলে 1–2 weeks।
  • Side effects: Headache, diarrhea/constipation, nausea; long-term use → hypomagnesemia, B12 deficiency, fracture risk, C. difficile risk।
  • Interactions: Omeprazole/esomeprazole may reduce clopidogrel activation; warfarin/phenytoin monitoring।
  • Bangladesh brands: Losectil 20 mg, Seclo 20 mg, Maxpro 20 mg, Sergel 20 mg, Pantonix 20/40 mg, Pantolok 20/40 mg; MedEx lists PPI indications including GERD and NSAID-induced ulcer prevention/treatment।

8) Local corticosteroid injection — De Quervain / Trigger finger

Triamcinolone acetonide

  • Generic name: Triamcinolone acetonide injection
  • Therapeutic category: Anti-inflammatory steroid
  • Pharmacological class: Synthetic glucocorticoid corticosteroid
  • কেন use হয়: Tendon sheath inflammation কমিয়ে pain/function দ্রুত improve করতে; De Quervain-এ thumb spica immobilization সহ ৩–৪ সপ্তাহ evidence-supported।
  • Dose: 10–20 mg local tendon sheath injection commonly; selected cases 20–40 mg. Intratendinous injection avoid।
  • Duration: Single injection; response assess 4–6 weeks; repeat only if needed, usually max 2–3 injections/site।
  • Side effects: Post-injection flare, local skin depigmentation/atrophy, tendon weakening/rupture, infection, transient hyperglycemia।
  • Interactions: Systemic interaction minimal, but diabetes patient-এর glucose rise; anticoagulant patient-এ bleeding risk assess।
  • Bangladesh brands: Trialon 40 mg/ml, Triacin 40 mg/ml, Triamon 40 mg/ml, Intracort 40 mg/ml, Trimcort 40 mg/ml—MedEx listed as triamcinolone acetonide injection; Trialon is described as synthetic glucocorticoid for IM/IA use।

Methylprednisolone acetate

  • Generic name: Methylprednisolone acetate injection
  • Therapeutic category: Anti-inflammatory steroid
  • Pharmacological class: Glucocorticoid corticosteroid
  • কেন use হয়: Local tendon sheath inflammation কমাতে steroid alternative।
  • Dose: 20–40 mg local tendon sheath injection with/without local anesthetic; aseptic technique mandatory।
  • Duration: Single injection; review 4–6 weeks।
  • Side effects/interactions: Triamcinolone-এর মতো।
  • Bangladesh brands: Depo-Medrol 40 mg/ml, Depo-Medrol 80 mg/2 ml, Depo-pred 40 mg/ml—MedEx listed।

Lidocaine local anesthetic

  • Generic name: Lidocaine hydrochloride
  • Therapeutic category: Local anesthetic
  • Pharmacological class: Amide local anesthetic; sodium-channel blocker
  • কেন use হয়: Steroid injection-এর সময় immediate analgesia/diagnostic pain relief।
  • Dose: 1% lidocaine 0.5–1 ml local; avoid intravascular injection।
  • Side effects: Local numbness, dizziness, tinnitus, seizure/arrhythmia if systemic toxicity।
  • Interactions: Class I antiarrhythmic drugs, beta-blockers/cimetidine may increase toxicity risk।
  • Bangladesh brands: Jasocaine 1%/2% injection, Jasocaine-A 2%+adrenaline—MedEx listed; MedEx describes lidocaine as sodium-channel blockade local anesthetic।

Steroid injection never use করবেন না যদি local infection, cellulitis, abscess, fever, pyogenic tenosynovitis suspicion থাকে।

9. Antibiotics — only if infective tenosynovitis/cellulitis/wound infection suspected

Clinical principle

  • Mild superficial cellulitis হলে oral antibiotic possible।
  • Suspected pyogenic flexor tenosynovitis হলে urgent admission, hand-surgery consult, IV antibiotic, elevation, splint, and usually surgical irrigation/debridement।
  • Antibiotic should be culture-guided where possible।

1) Flucloxacillin

  • Generic name: Flucloxacillin
  • Therapeutic category: Antibiotic
  • Pharmacological class: Anti-staphylococcal penicillin; beta-lactam
  • কেন use হয়: MSSA/Staph skin-soft tissue infection suspected হলে।
  • Dose: 500 mg PO 6 hourly, empty stomach।
  • Duration: 5–7 days; severe/deep infection হলে specialist-guided।
  • Side effects: GI upset, rash, cholestatic hepatitis, allergy/anaphylaxis।
  • Interactions: Warfarin INR effect possible, methotrexate toxicity risk, oral contraceptive counselling if vomiting/diarrhea।
  • Bangladesh brands: Flubex 500 mg, Cloxafu 500 mg, Cloxakil 500 mg—MedEx lists flucloxacillin for Gram-positive/Staph skin-soft tissue infections।

2) Cloxacillin

  • Generic name: Cloxacillin sodium
  • Therapeutic category: Antibiotic
  • Pharmacological class: Anti-staphylococcal penicillin
  • কেন use হয়: MSSA coverage; cellulitis/wound infection।
  • Dose: 500 mg PO 6 hourly before food।
  • Duration: 5–7 days।
  • Side effects/interactions: Flucloxacillin-এর মতো—GI upset, allergy, cholestasis; warfarin/methotrexate caution।
  • Bangladesh brands: A-Clox 500 mg, Cloxin 500 mg, Clobex 500 mg, Penclox 500 mg, Ambeeclox 500 mg—MedEx listed; A-Clox page lists adult oral dose 500 mg four times daily।

3) Amoxicillin + Clavulanic acid

  • Generic name: Amoxicillin + Clavulanic acid
  • Therapeutic category: Antibiotic
  • Pharmacological class: Aminopenicillin + beta-lactamase inhibitor
  • কেন use হয়: Bite wound, puncture wound, polymicrobial infection, beta-lactamase organism suspicion।
  • Dose: 625 mg PO 12 hourly; moderate infectionে 8 hourly can be used depending severity/local protocol।
  • Duration: 5–7 days; deep infection/surgery হলে longer culture-guided।
  • Side effects: Diarrhea, nausea, rash, candidiasis, cholestatic hepatitis, allergy।
  • Interactions: Warfarin INR rise, methotrexate toxicity, allopurinol rash risk।
  • Bangladesh brands: Moxaclav 500+125 mg, Augment 500+125 mg, Avloclav 500+125 mg, Amoclav 500+125 mg; MedEx lists 625 mg composition as amoxicillin 500 mg + clavulanic acid 125 mg।

4) Cephalexin

  • Generic name: Cephalexin
  • Therapeutic category: Antibiotic
  • Pharmacological class: First-generation cephalosporin
  • কেন use হয়: Mild skin-soft tissue infection with MSSA/Strep coverage।
  • Dose: 500 mg PO 6 hourly।
  • Duration: 5–7 days।
  • Side effects: Diarrhea, nausea, rash, candidiasis; beta-lactam allergy caution।
  • Interactions: Warfarin INR rise, metformin level increase possible, probenecid increases level।
  • Bangladesh brands: Acelex 500 mg, Ceporal 500 mg, Navalexin 500 mg, Neorex 500 mg, Selex 500 mg—MedEx listed।

5) Cefuroxime axetil

  • Generic name: Cefuroxime axetil
  • Therapeutic category: Antibiotic
  • Pharmacological class: Second-generation cephalosporin
  • কেন use হয়: SSTI/respiratory mixed coverage; selected cellulitis or wound infection।
  • Dose: 500 mg PO 12 hourly after food।
  • Duration: 5–7 days।
  • Side effects: Diarrhea, nausea, rash, candidiasis, C. difficile rare।
  • Interactions: Antacids/PPI may reduce absorption; warfarin INR monitoring।
  • Bangladesh brands: Cefotil 500 mg, Famicef 500 mg, Cefusil 500 mg, Cefuson 500 mg, Primocef 500 mg, Zenifor 500 mg—MedEx listed।

6) Clindamycin

  • Generic name: Clindamycin
  • Therapeutic category: Antibiotic
  • Pharmacological class: Lincosamide antibiotic
  • কেন use হয়: Penicillin allergy, suspected community MRSA, anaerobic component, abscess/cellulitis selected cases।
  • Dose: 300 mg PO 6–8 hourly; severe infectionে IV 600–900 mg 8 hourly hospital setting।
  • Duration: 5–7 days oral; severe infection culture-guided।
  • Side effects: Diarrhea, nausea, rash; major risk—C. difficile colitis।
  • Interactions: Neuromuscular blockers effect enhance; erythromycin antagonism; warfarin INR monitoring।
  • Bangladesh brands: Clindacin 150/300 mg, Climycin 300 mg, Clinacyn 150/300 mg, Clindax 150/300 mg, Clinex 150/300 mg, Dalacin C 300 mg; MedEx generic page lists many clindamycin brands and Clindacin 600 mg/4 ml injection।

7) Doxycycline

  • Generic name: Doxycycline hydrochloride
  • Therapeutic category: Antibiotic
  • Pharmacological class: Tetracycline antibiotic; protein synthesis inhibitor
  • কেন use হয়: Suspected community MRSA coverage; usually Strep coverage poor, so cellulitis pattern অনুযায়ী combine/alternative consider।
  • Dose: 100 mg PO twice daily।
  • Duration: 5–7 days; acne-like chronic indication নয় এখানে।
  • Side effects: Gastritis/esophagitis, photosensitivity, nausea, tooth discoloration in children, contraindicated pregnancy।
  • Interactions: Antacid, iron, calcium, zinc reduce absorption; warfarin effect ↑; phenytoin/carbamazepine reduce level।
  • Bangladesh brands: Doxicap 100 mg, Doxibac 100 mg, Doxcline 100 mg, Doxicline 100 mg, Doxilin 100 mg—MedEx listed; MedEx describes doxycycline as tetracycline-group broad-spectrum antibiotic and notes antacid/iron interaction।

8) Co-trimoxazole

  • Generic name: Sulfamethoxazole + Trimethoprim
  • Therapeutic category: Antibiotic
  • Pharmacological class: Folate synthesis inhibitor combination
  • কেন use হয়: Suspected MRSA skin infection selected cases; Strep coverage inadequate হতে পারে।
  • Dose: DS 800/160 mg PO twice daily।
  • Duration: 5–7 days।
  • Side effects: Rash, SJS/TEN rare, hyperkalemia, renal dysfunction, bone marrow suppression, GI upset।
  • Interactions: Warfarin major INR ↑, ACEi/ARB/spironolactone hyperkalemia, methotrexate toxicity, phenytoin।
  • Bangladesh brands: Cotrim DS 800+160 mg—MedEx listed।

9) Ceftriaxone — hospital/severe infection

  • Generic name: Ceftriaxone sodium
  • Therapeutic category: Antibiotic
  • Pharmacological class: Third-generation cephalosporin
  • কেন use হয়: Severe cellulitis, deep hand infection, sepsis, bone/joint involvement—hospital IV therapy; PFT-এ often anti-MRSA coverage সহ culture-guided regimen।
  • Dose: 1–2 g IV/IM once daily; severe infectionে divided or higher per protocol; max usually 4 g/day।
  • Duration: Clinical response/culture/surgery অনুযায়ী।
  • Side effects: Diarrhea, biliary sludging, allergy, cytopenia, injection pain।
  • Interactions: Calcium-containing IV solution with neonates contraindicated; warfarin INR ↑।
  • Bangladesh brands: Ceftron 1 g/vial, Axon 1 g/vial, Dicephin 1 g/vial, Cefone 1 g/vial, Ceftrix 1 g/vial—MedEx listed; Ceftron page lists skin/soft tissue, septicemia, bone/joint infections and 1–2 g daily dosing।

10) Vancomycin — severe MRSA risk/hospital

  • Generic name: Vancomycin hydrochloride
  • Therapeutic category: Antibiotic
  • Pharmacological class: Glycopeptide antibiotic
  • কেন use হয়: Severe suspected/confirmed MRSA infection, deep hand infection, sepsis risk; must monitor renal function and levels where available।
  • Dose: 15–20 mg/kg IV every 8–12 hours, renal function and therapeutic monitoring অনুযায়ী।
  • Duration: Culture, surgical findings, osteomyelitis আছে কিনা—এসব অনুযায়ী।
  • Side effects: Nephrotoxicity, infusion reaction/red-man syndrome, ototoxicity rare, neutropenia।
  • Interactions: Aminoglycosides, amphotericin, loop diuretics, NSAIDs → nephro/ototoxicity risk ↑।
  • Bangladesh brands: Vanmycin 500 mg/1 g vial, Vancard 500 mg/1 g, Vancin 500 mg/1 g, Vancomin 500 mg/1 g, Covan 500 mg/1 g—MedEx listed।

10. Bangladesh doctors’ prescription pattern — commonly used list

Non-infective tenosynovitis

  • Paracetamol 500 mg PRN — pain relief, NSAID avoid করলে safer।
  • NSAID short course:
    • Aceclofenac 100 mg BD, or
    • Naproxen 500 mg BD, or
    • Ibuprofen 400 mg TDS, or
    • Diclofenac 50 mg BD/TDS, or
    • Etoricoxib 60 mg OD.
  • PPI:
    • Omeprazole/Esomeprazole/Pantoprazole 20 mg OD—NSAID gastric protection।
  • Local steroid injection:
    • Triamcinolone acetonide or methylprednisolone acetate + lidocaine—De Quervain/trigger finger not improving or moderate-severe pain।
  • Splint:
    • Thumb spica or finger splint—drug-এর সাথে essential।

Infective tenosynovitis / wound-related

  • Oral antibiotics only if mild superficial infection and no Kanavel signs।
  • Flucloxacillin/Cloxacillin/Cephalexin/Cefuroxime—MSSA/Strep coverage।
  • Amoxicillin-clavulanate—bite/puncture/polymicrobial suspicion।
  • Clindamycin/Doxycycline/Co-trimoxazole—MRSA risk or penicillin allergy, local resistance অনুযায়ী।
  • Ceftriaxone ± Vancomycin—hospital severe/deep infection।
  • Surgical drainage/irrigation—PFT suspected হলে delay করা যাবে না।

11. Prevention — কীভাবে প্রতিরোধ করবেন

  • Repetitive hand/wrist activity-তে break নিন: প্রতি ৩০–৪৫ মিনিটে ২–৩ মিনিট।
  • Mobile/keyboard ergonomics ঠিক করুন।
  • Heavy lifting বা baby lifting-এ wrist neutral রাখুন।
  • Wrist/thumb support ব্যবহার করুন যদি repeated flare হয়।
  • Exercise:
    • gentle stretching,
    • tendon gliding,
    • grip strengthening after pain improves।
  • Diabetes, RA, gout, hypothyroidism control করুন।
  • Hand wound হলে:
    • দ্রুত clean করুন,
    • foreign body থাকলে remove,
    • tetanus status check,
    • infection signs দেখলে early doctor consult।
  • Steroid injection বারবার নেওয়া এড়িয়ে চলুন; tendon rupture risk থাকে।
  • Pain কমে গেলেই heavy activity restart করবেন না—gradual return।

12. Overview / Summary

Tenosynovitis হলো tendon sheath inflammation। Non-infective হলে pain, swelling, stiffness, triggering/locking হয় এবং treatment হলো rest, splint, NSAID, physiotherapy, selected local steroid injection। De Quervain tenosynovitis-এ steroid injection + thumb spica ৩–৪ সপ্তাহ evidence-supported first-line option। Infective flexor tenosynovitis হলে Kanavel signs খুঁজতে হবে এবং এটি emergency—IV antibiotic + hand-surgery drainage দরকার হতে পারে।

13. Actionable Plan / Steps

  1. Type identify করুন: De Quervain, trigger finger, overuse, inflammatory, না infective?
  2. Red flag check করুন: fever, puncture wound, severe swelling, Kanavel signs, diabetes/immunosuppression।
  3. Non-infective হলে: splint + activity modification + paracetamol/NSAID 3–7 days ± PPI।
  4. Moderate/severe De Quervain বা trigger finger: local steroid injection under aseptic technique; ultrasound-guided হলে better।
  5. Infection suspected হলে: CBC/CRP/ESR, culture, X-ray/US; urgent hand surgeon referral; IV antibiotic start after culture where feasible।
  6. Follow-up: 1–2 weeks; persistent locking/pain >6–8 weeks হলে ortho/hand surgery review।

14. Reference List — Textbook + Guideline + DOI

Textbooks

  1. Harrison’s Principles of Internal Medicine, 21st ed. Chapters: Rheumatoid Arthritis; Crystal Arthropathies; Bacterial Infections of Skin and Soft Tissues.
  2. Davidson’s Principles and Practice of Medicine, 24th ed. Chapters: Musculoskeletal disorders; Infectious diseases.
  3. Robbins & Cotran Pathologic Basis of Disease, 10th ed. Chapters: Inflammation and Repair; Musculoskeletal system.
  4. Katzung & Trevor’s Basic & Clinical Pharmacology, 16th ed. Chapters: NSAIDs; Corticosteroids; Beta-lactam antibiotics; Protein synthesis inhibitors.
  5. Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 14th ed. Chapters: Analgesic-antipyretic and anti-inflammatory agents; Antimicrobial agents.

Guidelines / Evidence sources

  1. Challoumas D, et al. Management of de Quervain Tenosynovitis: A Systematic Review and Network Meta-Analysis. JAMA Network Open. 2023;6(10):e2337001. DOI: 10.1001/jamanetworkopen.2023.37001.
  2. Giladi AM, Malay S, Chung KC. A systematic review of the management of acute pyogenic flexor tenosynovitis. J Hand Surg Eur Vol. 2015;40(7):720–728. DOI: 10.1177/1753193415570248.
  3. Kennedy CD, Huang JI, Hanel DP. In Brief: Kanavel’s Signs and Pyogenic Flexor Tenosynovitis. Clin Orthop Relat Res. 2016;474:280–284. DOI: 10.1007/s11999-015-4367-x.
  4. MSD Manual Professional. Infectious Flexor Tenosynovitis: diagnosis suggested by Kanavel signs; treatment surgical drainage and antibiotics.
  5. Ray G, et al. Tenosynovitis. StatPearls/NCBI Bookshelf. Updated 2023.

Md.Rafiqul Islam Lipu,Date:-15-06-2026 Wednesday,Time:-09-49-12 AM

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