Examkin

Question

Difficulty: HardOrthopedic Surgery

A 31-year-old male agricultural worker presents to the emergency department with a 3-day history of progressive pain and swelling in his left index finger. He reports sustaining a small puncture wound from a wire fence 5 days prior. His temperature is 38.1∘C38.1^\circ\text{C} (100.6∘F100.6^\circ\text{F}), blood pressure is 118/76 mmHg118/76\text{ mmHg}, and pulse is 98/min98/\text{min}. Physical examination reveals a diffusely swollen, erythematous left index finger that the patient holds in a partially flexed posture. There is pronounced tenderness extending along the volar aspect of the digit down to the proximal palmar crease. Passive extension of the finger elicits excruciating pain. Sensation and capillary refill are intact in the affected digit. Radiographs of the hand show soft tissue swelling but no foreign body, fracture, or bony destruction. Which of the following is the most appropriate next step in management?

  1. Immediate surgical irrigation and debridement of the flexor tendon sheathAnswer
  2. B
    Admission for intravenous broad-spectrum antibiotics and strict hand elevation
  3. C
    Magnetic resonance imaging of the hand to assess for deep space abscess or osteomyelitis
  4. D
    Longitudinal incision and drainage isolated to the volar pad of the distal phalanx
  5. E
    Bedside local corticosteroid injection and application of an aluminum finger splint

Answer

Immediate surgical irrigation and debridement of the flexor tendon sheath is the correct next step because the patient has acute suppurative flexor tenosynovitis, which is a surgical emergency.
The correct answer addresses the urgent need for surgical decompression in acute suppurative flexor tenosynovitis. The patient presents with the four classic Kanavel signs: 1) fusiform (sausage-like) swelling of the digit, 2) the digit is held in a flexed resting posture, 3) exquisite tenderness along the course of the flexor tendon sheath, and 4) severe pain elicited by passive extension of the finger. Because the flexor tendon sheath is a closed space with a tenuous blood supply, the accumulation of purulent material rapidly increases pressure, causing ischemia and necrosis of the tendon. Therefore, immediate surgical irrigation and debridement in the operating room, combined with intravenous antibiotics, is the definitive and mandatory next step to preserve digit function.

Step-by-Step Solution

1
Analyze the patient's history and physical examination findings.
The patient has a history of a puncture wound followed by fusiform swelling, a flexed resting posture, tenderness along the tendon sheath, and severe pain with passive extension.
Identifying these specific clinical features is necessary to recognize the four classic Kanavel signs.
2
Synthesize the physical findings to establish a diagnosis.
The presence of Kanavel signs confirms the clinical diagnosis of acute suppurative flexor tenosynovitis.
This specific pattern of infection behaves like compartment syndrome of the digit due to the closed space of the synovial sheath.
3
Determine the urgency and appropriate intervention based on the diagnosis.
Recognize this as a surgical emergency requiring immediate operative irrigation and debridement alongside intravenous antibiotics.
Delaying surgery or relying solely on antibiotics leads to sheath ischemia, tendon necrosis, and permanent loss of digit function.

Key Concept

Acute suppurative flexor tenosynovitis diagnosis and management
Estimated Time:1m 15s
Rate this question

Topics

Orthopedic Surgery

More questions from this topic