Too Evil and “Kanavel” to be Bored – Review

Published by Kylie Birnbaum on

knievel1

An epic stuntman known as Evel Knievel presents to the ER with intense finger pain. He noticed the pain start yesterday, a day after he nicked his index finger doing a flying motorcycle stunt. Although he’s broken 433 bones in his lifetime (true story- he’s in the Guinness book of World Records!) from stunts, it doesn’t appear that his finger is broken this time. He does have severe pain and says it’s so swollen and painful that he cannot move it.  On exam, he has a mild fever and otherwise normal vitals. His left index finger is uniformly swollen like a sausage. It’s held in flexed position. When you try to examine it or touch it he cries in pain.

The finger looks like this:

FT

 

What is your diagnosis?
Infectious flexor tenosynovitis! Infection of the flexor tendon sheath of the finger. Often from penetrating trauma, but the patient may not notice an inciting event. This is a surgical emergency as it can rapidly spread proximally and destroy the finger’s function. In your workup, be sure to send CBC, ESR, blood cultures and get finger/hand XRays.  

 

What are Kanavel's Four Cardinal signs of this disease?
  1. Percussion tenderness – over the entire length of the tendon sheath
  2. Uniform / fusiform swelling of the digit, aka “sausage digit.” Yum!
  3. Intense pain with passive extension
  4. Flexed posture of the digit at rest

 

What is the treatment?
Flexor tenosynovitis often caused by Staph. Start empiric antibiotics quickly, usually with vancomycin. However, also consider gonorrhea if the patient has a STD history and start ceftriaxone. Immobilize and elevate the hand. Consult the hand surgeons for immediate evaluation. This is a surgical emergency and definitive treatment is surgery. If caught early enough it may be managed conservatively with IV antibiotics, yet you should always get the surgery team on board ASAP.

 

Evel Knieval ... 433 bone fractures?!?
 Indeed. Ironically, before he was a daredevil stuntman he was an insurance salesman! And perhaps more ironically, after surviving endless crashes, bone fractures, and even Hepatitis C with a liver transplant, he died in 2007 from pulmonary fibrosis. Isn’t it ironic, don’t ya think?

 

References

Photo cred: https://drhem.wordpress.com/tag/tenosynovitis/

Tintinalli’s 7th ed., Ch 280.

https://en.wikipedia.org/wiki/Evel_Knievel

 

 

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Kylie Birnbaum

Emergency Medicine Resident at Kings County Hospital / SUNY Downstate @KBirnbaumMD
Categories: EM Principles
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Kylie Birnbaum

Emergency Medicine Resident at Kings County Hospital / SUNY Downstate

@KBirnbaumMD

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