VizD Vol 1.2

Case 1.2

A 35-year-old man presents to your ED after cutting his finger on the back of a refrigerator that he was moving for a friend.  He washed the finger and placed a bandage over it.  However, upon waking up this morning, he noticed increased redness and swelling as seen in the image below.

Questions:

1. What is the diagnosis?

2. What are Kanavel’s 4 cardinal signs?

3. What is the ED disposition?

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

VizD is a weekly contest of an interesting or pathognomonic image from emergency medicine. Its goal is to integrate learning into a fun and relaxed environment. All images are original and are posted with the consent of the patient.

11 Responses

  1. tenosynovitis

    Finger is usually flexed slightyly for comfort…Pain with attempt to extend….uniform swelling of finger…tenderness along course of tendon

    hand consult and admit for iv abx.

  2. diagnosis: flexor tenosynovitis
    Kanaval signs: finger held in flexion, fusiform swelling, tenderness along flexor tendon sheeth, pain with passive extension of the digit
    Disposition: admit to medicine for IV antibiotics

  3. Flexor tenosynovitis

    4 signs: intense pain with attempted extension, finger held in flexion, swelling, tenderness to palpation extending down flexeor tendon sheath

    dispo: admit for IV antibiotics and hand surgery consult; may need debridement

  4. 1) infectious tenosynovitis

    2)
    – intense pain accompanies any attempt to extend partly flexed finger
    – flexion posture: finger is held in flexion for comfort;
    – uniform swelling involving entire finger in contrast to localized swelling in local inflammation;
    – percussion tenderness along the course of the tendon sheath;
    – tenderness is marked along the course of inflammed sheath in contrast to its absence in a localized inflammation;

    3) If the diagnosis is equivocal, admission to a hand specialist (eg, plastic surgery, orthopedics), elevation, and broad-spectrum antibiotics to include staphylococcal and/or streptococcal bacterial coverage are necessary.

    Add anaerobic coverage if anaerobic infection is likely (ie, with cat or human bites). If the diagnosis of tenosynovitis is definite, refer to hand specialist for urgent surgical incision and drainage.

    sources: emedicine.com and Wheeless’ Textbook of Orthopaedics

  5. infectious tenosynovitis

    pain w/extension of partially flexed finger
    flexion posture for comfort
    uniform swelling of entire finger, instead of local inflam
    percussion tenderness along course of tendon sheath

    plastics for hand at DRH and admit with broad spectrum antibiotics, i.v. coverage

  6. oops…sent prematurely..

    1) Flexor tenosynovitis
    2) Kanavel’s 4 cardinal signs:
    1)finger held in flexed position, 2)diffuse swelling of the finger, 3)increased pain with passive extension of finger, 4)pain over palpation of flexor tendon sheath
    3) Dispo: I&D needed, start of IV antibiotics, consult to hand if available

  7. May be tenosynovitis; however, need an US to rule out or in – may just be an abscess. Had a great case of pt with similar findings but on US of the hand actually had an abscess and no tenosynovitis. Had all of Kanavel’s signs however.

  8. DX: Flexor Tenosynovitis
    Kanaval’s Signs
    1 flexd position
    2 pain with passive ROM/extension
    3 edema of the entire finger
    4 pain along teh tendon sheath

    Dispo: Admit for IV antibiotics (staph and strep), hand surgery consult, tetanus booster.

  9. infectious/flexor tenosynovitis
    1. severe pain
    2. finger held in flexion
    3. uniform edema along the tendon sheath
    4. tenderness to percussion of tendon sheath
    IV abx, admit, hand consult, tetanus, amputate

  10. 1. Flexor Tenosynovitis
    2. Kanavel’s 4 cardinal signs: (1) symmetric swelling of finger (2) pain on passive extension (3) tenderness along course of flexor tendon (4) flexed finger
    3. ED disposition: Admission, IV Abx, Hand surgery consult

  11. Not that I’m impressed a lot, but this is a lot more than I expected for when I stumpled upon a link on SU telling that the info is quite decent. Thanks.

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