Edited by Jonathan Lans and CJ Nessralla - 7/1/2021
Descriptors
Pyogenic flexor tenosynovitis
Exam Pearls
Upper extremity neurovascular exam
Kanavel’s Signs
- Fusiform swelling
- Pain with palpation along the flexor sheath
- Flexed position of the digit
- Pain with passive extension of the digit
History: penetrating trauma common
Workup
Radiographs: AP/lateral/oblique affected finger (assess for foreign body)
Other imaging: can consider CT to look for deep space abscess if concerned
Labs: WBC, ESR, CRP; pre-op labs
Other: None
Management
Hand consults should be staffed with attending/fellow prior to definitive management.
Need for acute intervention:
Yes, generally immobilization in volar resting splint, skyhook, add on for I&D of flexor tendon sheath in the OR.
Weight-bearing and range of motion: NWB in volar resting splint with strict elevation in skyhook.
Type of immobilization: Volar resting splint, skyhook.
Admission or discharge status:
Early and mild presentation (<24hrs of symptoms): Admission to ED Obs for IV antibiotics and repeat evaluation. NPO.
Late or moderate to severe presentation (>24hrs of symptoms): Admission to Hand Service for operative treatment.
Anticoagulation: None
Antibiotics: IV Vancomycin. Consider Unasyn or Zosyn for Gram negative/anaerobe coverage.
Surgical Indications
Absolute: Subcutaneous purulence, digital ischemia, systemic sepsis, >24hrs of symptoms, failure of trial of antibiotics
Relative: age >40 years, DM, peripheral vascular disease, CKD.
Not an indication: N/A