II. Definition
- Closed space Infection within hand flexor tendon sheath
III. Pathophysiology
-
Synovial Fluid is an ideal medium for Bacterial growth
- Tendon sheaths have a poor vascular supply
- Synovial Fluid collection
IV. Causes: Organisms
- Most common causative organisms
- Other infections
- Gram Negative Bacteria (10% of responsible organisms)
- Disseminated Neisseria gonorrhoeae
- Disseminated candida albicans (immunocompromised patients)
- Mixed oral anaerobic and aerobic Bacteria (Injection drug use)
V. Mechanisms
- Deep penetrating wound to the palmar surface of the hand or finger (most common)
- Blunt Hand Trauma
- Extension of felon
- Puncture Wound of finger
-
High Pressure Injection Wounds
- Paint injection (most toxic!)
- Oil or grease injection
- Disseminated Infection (e.g. Neisseria gonorrhoeae)
VI. Risk Factors
- Immunocompromised patients (e.g. HIV Infection)
- Worse outcomes with >5 years of Tobacco Abuse
- More serious infections, delayed Wound Healing
VII. Signs
- Febrile and toxic appearing patient
- Kanavel's four cardinal signs
- Finger is uniformly swollen (digital fusiform swelling)
- Finger held in slight flexion for comfort
- Course of inflamed sheath is markedly tender
- Passive finger extension causes intense pain
- Highly sensitive for flexor tendon infection
VIII. Differential Diagnosis
- Deep space abscess (localized tenderness)
- Animal Bite
- Clenched-fist Injury (Fight Bite)
- Necrotizing Fasciitis
- Disseminated Candida albicans (Immunocompromised patients)
- Disseminated Neisseria gonorrhoeae
- Osteomyelitis
- Septic Joint
IX. Diagnostics
- Ultrasound may show tendon effusion or abscess
X. Management
- Early recognition and treatment is critical
- Consult hand surgery urgently (within 72 hours)
- Hand surgery indications: No improvement in 24 hours of antibiotics
- Minimal incision with catheter irrigation of tendon sheath (preferred) OR
- Wide Incision and Drainage
- May be indicated in High Pressure Injection Wound
- Extremity elevation and Splinting
- Remove rings from fingers
- Initial parenteral antibiotics
- First-line parenteral coverage for MRSA
- Vancomycin
- Daptomycin
- Linezolid
- Televancin
- Clindamycin (depending on local sensitivities to MRSA)
- Injection drug use (polymicrobial coverage as well as MRSA)
- Vancomycin AND
- Piperacillin/Tazobactam (Zosyn)
- Disseminated Neisseria gonorrhoeae suspected
- Older antibiotic regimens that may be considered in more mild, borderling cases (Streptococcus, Staphylococcus)
- Cefazolin (Ancef) or
- Ampicillin-sulbactam (Unasyn) or
- First-line parenteral coverage for MRSA
- Later oral antibiotics for home
- Continue for 5 to 14 days after discharge
- Following initial surgical and antibiotics management
- Occupational therapy (hand therapy) Consultation
XI. Complications: Acute
- Contiguous spread of Infection throughout hand
- Associated with rapid increase in pressure
- Pus accumulation
- May obliterate tendon blood supply
- Results in tendon necrosis, function loss, and ultimately tendon rupture
XII. Complications: Chronic
- Chronic finger stiffness and reduced function
- Finger Amputation due to worsening infection
XIII. References
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Related Studies (from Trip Database) Open in New Window
| 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 | tenosynovitis infective (diagnosis), tenosynovitis infective, 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 |
