- History and Physical:
- time of injury and symptoms;
- exact position of hand (finger flexion) during the injury
- kanavel's signs:
- used to distinguish deep infectious tenosynovitis from superficial cellulitis;
- pain w/ finger extension may be the earliest sign present;
- bite wounds
- bacteriology of hand infections:
- bites distal to the wrist are at higher risk for malignant infections due to the proximity of superficial spaces, flexor tendons, and joints;
- Diff Dx: (simulators of hand infections)
- acute calcific tendinitis
- look for calcific deposit at tendon insertion (FCU most common);
- pyogenic granuloma
- pyoderma gangrenosum
- gout:
- gout should be considered in older males who present w/ acute tenosynovitis in the hand, joint swelling, or soft tissue swelling;
- brown recluse spider bite
- Radiographs:
- w/ osteomyelitis, amputation is considered;
- w/ gas in the soft tissues consider emergent Incision and Drainage;
- Non Operative Treatment:
- IV antibiotics are used for superficial cellulitis;
- if infectious tenosynovitis is diagnosed within 24 to 48 hrs of onset of symptoms, it may also be treated w/ antibiotics, along w/ splinting and hand elevation;
- note, however, that operative treatment is usually required;
- Surgical Treatment:
- see: closed suction drainage:
- if there is no dramatic improvment after 24 hrs of antibiotics or if injury is more than 48 hours old, surgical drainage is indicated;
- if tendon sheath infection is seen late or is not treated properly early, skin loss, tendon necrosis, & subsequent osteomyelitis can result;
- Deep Infections:
- dorsal subaponeurotic infections:
- deep penetrating injury
- dorsal swelling, erythema, pain;
- I & D with two longitudinal incisions between the extensor tendons;
- wound is left open but the extensor tendons are covered;
- web space infections: (see thenar space infections)
- web space penetration, calloused palmar skin or blister;
- begins palmarly then dorsally (collar button abscess)
- separation of adjoining fingers;
- I and D of dorsal and palmar incisions