Answer VizD 1.2

VizD Winners:

Brian Kern                Marjan Siadat         Dave Mishkin

Scott Ottolini            Rob Klever

Devon Moore            Hong Chong

Richard Gordon        Allison Loynd

Answer to 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?

Answers:

1. Pyogenic Flexor Tenosynovitis – inflammation of the tendon and the surrounding synovial sheath, typically results from a puncture wound

2. Kanavel’s Four Cardinal Signs of Flexor Tenosynovitis

  • finger held in slight flexion
  • symmetric swelling of the finger (sausage digit)
  • tenderness along the flexor tenon sheath
  • pain with passive extension of the finger

3. I.V. antibiotics, immoblization, elevation.  Hand surgeon consultation within 24-hours for incision and drainage

**if there is no history of trauma in a sexually active adult, consider disseminated GC and treat empirically with ceftriaxone until culture results are available**

_____________________________________________

“Morrison’s Pouch”

Please welcome our newest contributor to Receiving…Dr. Daniel Morrison, Director of Emergency Medicine Ultrasound for Detroit Medical Center.  Dr. Morrison is going to be leading the Ultrasound Section of Receiving.

If Dr Morrison cared for the patient in the clinical scenario above, an ultrasound of the finger would have been obtained to confirm the diagnosis of flexor tenosynovitis.  Included in the differential diagnosis is cellulitis and abscess of the digit without tendon involvement. (click on images to enlarge)

Normal Tendon

Finger Abscess Without Involvement of Tendon

Flexor Tenosynovitis (Fluid around tendon sheath)

Thank you to everyone who submitted their answer.  Stay tuned for next week’s VizD

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.

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