II. Definition

  1. Infection within flexor tendon sheath

III. Pathophysiology

  1. Staphylococcus aureus and Streptococcus are the most common causative organisms

IV. Causes

  1. Extension of felon
  2. Puncture Wound of finger
  3. High Pressure Injection Wounds
    1. Paint injection (most toxic!)
    2. Oil or grease injection
  4. Disseminated Neisseria gonorrhoeae

V. Risk Factors

  1. Immunocompromised patients (e.g. HIV Infection)

VI. Complications

  1. Contiguous spread of Infection throughout hand
  2. Associated with rapid increase in pressure
    1. Pus accumulation
    2. May obliterate tendon blood supply
    3. Results in tendon necrosis and function loss

VII. Signs

  1. Febrile and toxic appearing patient
  2. Kanavel's four cardinal signs
    1. Finger is uniformly swollen
    2. Finger held in slight flexion for comfort
    3. Course of inflamed sheath is markedly tender
    4. Passive finger extension causes intense pain
      1. Highly sensitive for flexor tendon infection

VIII. Differential Diagnosis

  1. Subcutaneous abscess (localized tenderness)

IX. Diagnostics

  1. Ultrasound may show tendon effusion or abscess

X. Management

  1. Early recognition and treatment is critical
  2. High dose antibiotics
    1. Initial parenteral antibiotics
      1. General coverage (Streptococcus, Staphylococcus)
        1. Cefazolin (Ancef) or
        2. Ampicillin-sulbactam (Unasyn) or
      2. Neisseria gonorrhoeae suspected
        1. Ceftriaxone (Rocephin)
        2. Fluoroquinolone
    2. Later oral antibiotics for home
      1. Continue for 5 to 14 days after discharge
  3. Extremity elevation and Splinting
  4. Remove rings
  5. Early surgical evaluation
    1. Wide Incision and Drainage
      1. If no improvement in 24 hours with antibiotics
      2. Prevents tendon sloughing
  6. High Pressure Injection Wound treatment
    1. Requires extensive debridement and decompression

Images: Related links to external sites (from Google)

Ontology: Kanavel's four cardinal signs (C0231673)

Concepts Sign or Symptom (T184)
SnomedCT 35221005
English Kanavel four cardinal signs, Kanavel's four cardinal signs, Kanavel's four cardinal signs (finding)
Spanish cuatro signos cardinales de Kanavel (hallazgo), cuatro signos cardinales de Kanavel

Ontology: Infective tenosynovitis (C0847403)

Concepts Disease or Syndrome (T047)
Italian Tenosinovite infettiva
Japanese 感染性腱鞘炎, カンセンセイケンショウエン
Czech Infekční tendosynovitida
Hungarian infectiv tendovaginitis
English Infective tenosynovitis, infective; tenosynovitis, tenosynovitis; infective
Dutch infectieus; tendovaginitis, tendovaginitis; infectieus, infectieuze tenosynovitis
Portuguese Tenosinovite infecciosa
Spanish Tenosinovitis infecciosa
French Ténosynovite infectieuse
German infektioese Tenosynovitis