Ortho Case of the Week – Hand Soft Tissue Answers
Case 1: 30 year old female presents with right middle finger pain and swelling after getting bit by her cat 4 days ago, but she did not seek medical care at that time.
1. What is the feared diagnosis?
(Pyogenic) Flexor Tenosynovitis – an infection of the synovial sheath surrounding the flexor tendon.
2. What are the four Kanavel Signs?
Kanavel signs:
- Digit held in flexion at rest
- Tenderness to palpation the along tendon sheath
- Fusiform swelling of the affected digit (“sausage digit”)
- Pain with passive extension of the digit
3. What is the treatment?
- Empiric IV antibiotics targeted at the most common species (staph>MRSA>other skin flora>mixed flora). Start immediately if suspected but consider obtaining wound culture if any spontaneous drainage is present):
- Vancomycin AND
- Ampicillin/sulbactam, cefoxitin, OR piperacillin/tazobactam (includes Pseudomonal coverage)
- If marine exposure, consider adding fluoroquinolone, TMP/SMX, or doxy
- Emergent orthopedics consult for surgical I&D and washout.
Case 2: A 37 year old male presents with right thumb pain after a skiing accident where he fell backwards with his right hand landing awkwardly on his pole. Plain films are pending. On exam he is unable to maintain a “pincer” grasp (thumb and index finger opposition) and has laxity at the MCP compared to the other side.
1. What is your working diagnosis?
Ulnar collateral ligament injury, also known as gamekeeper’s thumb or skier’s thumb. Plain film may or may not show small avulsion fracture.
2. How would you treat it?
Treatment is thumb immobilization with as a thumb spica splint and orthopedics follow-up within one week.
Case 3: 26 year old male presents after a rugby game with the exam below, unable to bend at the ring finger DIP.
1. What is the diagnosis?
Jersey finger is a distal flexor tendon injury via avulsion from base of distal phalanx, often caused by the tip of a finger (most commonly 4th digit) getting caught in the jersey of another player who is running away. The affected digit is usually in relative extension. Treatment is usually surgical.
This is in contrast to mallet finger, which is an injury to the terminal extensor tendon distal to the DIP of the affected digit, often caused when a ball impacts and extended digit. The affected is usually in slight flexion. Treatment is continuous immobilization of only the DIP for 6-8 weeks duration.
2. How would you treat it?
The treatment for jersey finger is splinting the affected finger in slight flexion at the DIP, with close orthopedics follow up in 24 to 48 hours as definitive treatment is usually surgical.
3. How do you test the tendon functions of the individual digits on exam?
To test individual digit tendon function, manually immobilize the portion of the the digit immediately proximal to the segment of inquiry and ask the patient to flex and extend.
4. Should you as an ED Doc attempt to repair flexor or extensor tendons of individual digits?
You may attempt to repair EXTENSOR tendons with close orthopedics follow-up. Flexor tendon injuries should not be repaired in the emergency department. Both injuries should be splinted in the position of function and have follow-up with orthopedics within 7 days.
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