II. Definition

  1. Closed space Infection within hand flexor tendon sheath

III. Pathophysiology

  1. Synovial Fluid is an ideal medium for Bacterial growth
    1. Tendon sheaths have a poor vascular supply
    2. Synovial Fluid collection

IV. Causes: Organisms

  1. Most common causative organisms
    1. Staphylococcus aureus
    2. Streptococcus
  2. Other infections
    1. Gram Negative Bacteria (10% of responsible organisms)
    2. Disseminated Neisseria gonorrhoeae
    3. Disseminated candida albicans (Immunocompromised patients)
    4. Mixed oral anaerobic and aerobic Bacteria (Injection drug use)

V. Mechanisms

  1. Deep penetrating wound to the palmar surface of the hand or finger (most common)
  2. Blunt Hand Trauma
  3. Extension of felon
  4. Puncture Wound of finger
  5. High Pressure Injection Wounds
    1. Paint injection (most toxic!)
    2. Oil or grease injection
  6. Disseminated Infection (e.g. Neisseria gonorrhoeae)

VI. Risk Factors

  1. Immunocompromised patients (e.g. HIV Infection)
  2. Worse outcomes with >5 years of Tobacco Abuse
    1. More serious infections, delayed Wound Healing

VII. Signs

  1. Febrile and toxic appearing patient
  2. Kanavel's four cardinal signs
    1. Findings
      1. Finger is uniformly swollen (digital fusiform swelling)
      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
    2. Efficacy
      1. Test Sensitivity: 91 to 97%
      2. Test Specificity: 51 to 69%
      3. Kennedy (2017) Hand 12(6):585-90 +PMID: 28720000 [PubMed]

VIII. Differential Diagnosis

  1. Deep space abscess (localized tenderness)
  2. Felon
  3. Cellulitis
  4. Animal Bite
  5. Clenched-fist Injury (Fight Bite)
  6. Necrotizing Fasciitis
  7. Disseminated Candida albicans (Immunocompromised patients)
  8. Disseminated Neisseria gonorrhoeae
  9. Osteomyelitis
  10. Septic Joint

IX. Diagnostics

  1. Ultrasound may show tendon effusion or abscess

X. Management

  1. Early recognition and treatment is critical
  2. Consult hand surgery urgently (within 72 hours)
  3. Hand surgery indications: No improvement in 24 hours of antibiotics
    1. Minimal incision with catheter irrigation of tendon sheath (preferred) OR
    2. Wide Incision and Drainage
      1. May be indicated in High Pressure Injection Wound
  4. Extremity elevation and Splinting
  5. Remove rings from fingers
  6. Initial parenteral antibiotics
    1. First-line parenteral coverage for MRSA
      1. Vancomycin
      2. Daptomycin
      3. Linezolid
      4. Televancin
      5. Clindamycin (depending on local sensitivities to MRSA)
    2. Injection drug use (polymicrobial coverage as well as MRSA)
      1. Vancomycin AND
      2. Piperacillin/Tazobactam (Zosyn)
    3. Disseminated Neisseria gonorrhoeae suspected
      1. Ceftriaxone (Rocephin)
    4. Older antibiotic regimens that may be considered in more mild, borderline cases (Streptococcus, Staphylococcus)
      1. Cefazolin (Ancef) or
      2. Ampicillin-sulbactam (Unasyn) or
  7. Later oral antibiotics for home
    1. Continue for 5 to 14 days after discharge
  8. Following initial surgical and antibiotics management
    1. Occupational therapy (hand therapy) Consultation

XI. Complications: Acute

  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, function loss, and ultimately tendon rupture

XII. Complications: Chronic

  1. Chronic finger stiffness and reduced function
  2. Finger Amputation due to worsening infection

Images: Related links to external sites (from Bing)

Related Studies

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 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