II. Definition
- Infection within hand flexor tendon sheath
III. Pathophysiology
- Staphylococcus aureus and Streptococcus are the most common causative organisms
IV. Causes
- Deep penetrating wound to the palmar surface of the hand (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 Neisseria gonorrhoeae
V. Risk Factors
- Immunocompromised patients (e.g. HIV Infection)
VI. Complications
- Contiguous spread of Infection throughout hand
- Associated with rapid increase in pressure
- Pus accumulation
- May obliterate tendon blood supply
- Results in tendon necrosis and function loss
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
- Subcutaneous abscess (localized tenderness)
IX. Diagnostics
- Ultrasound may show tendon effusion or abscess
X. Management
- Consult hand surgery urgently
- Early recognition and treatment is critical
- High dose antibiotics
- Initial parenteral antibiotics
- General coverage (Streptococcus, Staphylococcus)
- Cefazolin (Ancef) or
- Ampicillin-sulbactam (Unasyn) or
- Neisseria gonorrhoeae suspected
- General coverage (Streptococcus, Staphylococcus)
- Later oral antibiotics for home
- Continue for 5 to 14 days after discharge
- Initial parenteral antibiotics
- Extremity elevation and Splinting
- Remove rings from fingers
- Early surgical evaluation
- Wide Incision and Drainage
- If no improvement in 24 hours with antibiotics
- Prevents tendon sloughing
- Wide Incision and Drainage
-
High Pressure Injection Wound treatment
- Requires extensive debridement and decompression
XI. Complications
- Chronic finger stiffness and reduced function
- Finger Amputation due to worsening infection
XII. References
- Hori (2015) Crit Dec Emerg Med 29(3): 2-7
- Boles (1998) Hand Clin 14:567-78 [PubMed]
- Clark (2003) Am Fam Physician 68:2167-76 [PubMed]
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| 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 |
