Hand Case Discussion 1.2

Hand Icon

Presented by: Jeff McMenomy, MD

CC: “My finger hurts.”

HPI: A 56 year-old right hand dominant male with history of type II diabetes mellitus presents with complaint of progressively worsening right index finger pain and swelling.  He says symptoms began about 6 hours ago.  He denies any trauma to the finger.  He complains of pain with any movement of the finger and states that he has exquisite pain whenever the finger accidently bumps against an object.  He has never had finger pain like this before.  This patient denies any fever or chills.

Past Medical History: Diabetes mellitus type II, hypertension

Past Surgical History: Tonsillectomy and adenoidectomy as a child

Family History: Positive for diabetes and hypertension; negative for heart disease or stroke

Social History: 10 pack-year smoking history, quit 5 years ago; denies ethanol or illicit drug use

Allergies: No known drug allergies

Medications: metformin, hydrochlorothiazide

Physical Exam:

Temp 36.8,     HR 92,     BP 140/91,     RR 18,      O2 Sat 98% on room airConstitutional: Alert and Oriented x 3, nontoxic-appearing

Musculoskeletal:

Right index finger is uniformly swollen and held in partial flexion.  This finger is exquisitely tender along the flexor surface and tenderness extends proximal to the flexor surface of the hand over the second metacarpal. The right index finger is only mildly tender over the extensor surface and there is no tenderness elsewhere on the hand or over any of the other fingers.  Patient has exquisite tenderness with passive extension of the right index finger but only mild tenderness with passive flexion.  There is mild erythema over the flexor surface of the right index finger which does not extent to the rest of the hand or to any other fingers.  There is no palpable fluctuance.  Patient is able to actively flex and extend at all joints of the right index finger, including the distal interpahalangial joint when this joint is isolated.  He does, however have pain with these movements.  There is no pain or deficits with active flexion or extension of any of the other fingers of the right hand.

Radiographs: Three-view x-ray of right index finger and hand shows soft tissue swelling of right index finger but no fracture or dislocation

Questions:

1.  Given this patient’s presentation, which of the following possible condition is of greatest concern?

a.  Dorsal finger soft tissue abscess with surrounding cellulitis

b.  Felon

c.  Flexor tendon tenosynovitis

d.  Herpetic whitlow

e.  Traumatic rupture of flexor tendon

2. What is the definitive treatment for the condition of greatest concern in this patient?

a.  Bedside nail bed repair, splinting, and arrange for follow-up in hand surgery clinic

b.  Bedside repair of ruptured tendon and arrange for follow-up in hand surgery clinic

c.  Hand surgery consult for operative intervention with initiation of parenteral antibiotics

e.  Local incision and drainage of abscess with gauze packing strip and follow-up in 2 days for wound check and removal of packing gauze

f.  Prescription for oral acyclovir, hand hygiene recommendations, and primary care follow up

3. What is the most common organism isolated from such lesions?

a.  Herpes simplex virus type 1

b.  Herpes simplex virus type 2

c.  Neisseria bacteria

d.  Pseudomonas bacteria

e.  Staphylococcus bacteria

Answers:

1.  c.  Flexor tendon tenosynovitis

The most concerning condition consistent with this patient’s signs and symptoms is flexor tendon tenosynovitis.  The classic description of flexor tendon tenosynovitis involves Kanavel’s four cardinal signs, all of which are present here.  There are: tenderness over the flexor tendon sheath, uniform swelling of the involved digit, pain with passive extension, and a semiflexed resting position of the involved digit.  Such infections are most commonly caused by penetrating trauma but commonly patients do not recall any trauma to the digit.

2.  c.  Hand surgery consult for operative intervention with initiation of parenteral antibiotics

Early recognition of this condition and evaluation by a hand surgeon for prompt operative intervention is essential.  Delay in recognition and treatment may result in loss of use of the involved finger and possibly the involved hand.  All patients must be admitted to the hospital and IV antibiotics should be started promptly.

3.  e.  Staphylococcus bacteria

Staphylococcus is the most common bacteria isolated in such infections and antibiotic coverage should cover this organism.  If MRSA is suspected, vancomycin may be administered.  Neisseria gonnorrhoeae should be considered in all patients with suspicion for sexually transmitted infection and is a possible hematogenous source, especially in patients with no history of penetrating trauma to explain the source of infection.  Ceftriaxone may be considered in such patients.

References

JA Marx, et al. (2006). Rosen’s Emergency Medicine: Concepts and Clinical Practice, Sixth Edition. Philadelphia: Mosby Elsevier.

JE Tintinalli, GD Kelen, JS Stappczynski. (2004). Emergency Medicine: A Comprehensive Study Guide, Sixth Edition. Chicago: McGraw-Hill.

RG Hart, DT Uehara, MJ Wagner. (2001).  Emergency and Primary Care of the Hand. Dallas: American College of Emergency Physicians.

“Hand Case Discussion” is an educational module that focuses on the diganosis and management of Hand pathology that commonly presents to the Emergency Department.

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