Rosh Review A1.1


Q. Which of the following is classically seen in flexor tenosynovitis?

A. Extended position of the involved digit

B. Fusiform swelling of the digit

C. Tenderness over the extensor sheath

D. Vesicular eruption over the flexor surface

The flexor tendons of the fingers are covered by a double layer of synovium to promote gliding of the tendon underneath. Infections in the synovial spaces in the hand tend to spread along the course of the flexor tendon sheaths and may extend proximally to the hand. Infections are usually due to penetrating trauma involving the sheath, but occasionally from hematogenous spread. There are four cardinal signs of acute flexor tenosynovitis that are usually present to help distinguish tenosynovitis from other hand infections. These criteria are referred to as the Kanavel signs.

Kanaval Criteria for Flexor Tenosynovitis
Tenderness along the course of the flexor tendon
Fusiform or symmetrical swelling of the finger
Pain with passive range of motion
A flexed posture of the finger

Flexor tenosynovitis is a surgical emergency. Consultation with a hand surgeon is warranted along with intravenous antibiotics.

The affected digit is held in a flexed (A), not extended posture. The tenderness is over the flexor (C) sheath, not extensor. Vesicles (D) are not commonly associated with flexor tenosynovitis. A localized herpes simplex infection may cause vesicles to form on a digit.

Ref: Lyn ET, Mailhot T: Hand, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch)47:p 521-522.

All Questions are taken from

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.


1. What is the diagnosis?

2. What are Kanavel’s 4 cardinal signs?

3. What is the ED disposition?


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.