Pre-teen male with no PMH presents to the ED after a dog bite the night before. Patient was bit on the palm of his left hand by a relative’s pit bull known to be fully vaccinated. Wound had been becoming more painful and 3rd digit is more swollen, painful, and difficult to range. No other injuries or complaints.
Two sub-centimeter puncture wounds to the center of the palm of the left hand, hemostatic with small amount of surrounding erythema present. 3rd digit with fusiform soft tissue swelling, increased warmth, and significant tenderness to palpation. Finger in slightly flexed positioning. Decreased ROM of the 3rd digit with flexion and significant pain with passive extension. Sensation intact to light touch throughout digits and hand. No other erythema, swelling, or significant tenderness present over LUE. 2+ palpable radial and ulnar pulses present.
No fracture or acute changes. No foreign body present.
Patient was admitted and was started on IV antibiotics for suspected pyogenic flexor tenosynovitis. Wound was rechecked in the morning with minimal improvement in symptoms and patient underwent I&D of digit and hand with continued IV antibiotics.
Pyogenic flexor tenosynovitis = infection of synovial sheath surrounding the flexor tendon
Pain/swelling usually delayed 24-48 hours, usually localized to the palmar aspect of one digit of the hand
Kanavel signs – key physical exam findings for diagnosis
Obtain x-rays to rule out bony involvement or foreign body
MRI can help diagnose but is expensive and generally unnecessary since clinical exam usually is sufficient
If early presentation:
If late presentation or if no improvement after 24 hours of conservative treatment:
Empiric Abx to consider:
Otherwise healthy individuals--
Consider with dog bites-- most are polymicrobial:
History and physical examination is key to diagnosis
Start antibiotics early
Consider surgical intervention when there is:
o flexor tendon sheath
o deep spaces of the palm
o joint spaces
Kanavel signs may not be seen if patient has:
CMC ER Residents
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