Thorsang Chayovan5th year medical student

ผูป่้วยหญงิไทย อาย ุ23 ปี

Chief Complaint :เจบ็ปวดที่ น้ิวนางมือซา้ย มา 2 วนั

Present History : ปฏเิสธอบุตัเิหต ุขยบัน้ิวนางปวดมาก ไม่มีไข ้

ตรวจร่างกาย น้ิวนางบวมแดง เจบ็เม่ือมีการขยบั

Pain Stiffness Fever Previous history Underlying disease Systemic inflammatory disease manifestation

(RA, SLE, gout) Trauma history Lifestyle Family history

Inspection Signs of Inflammation

Deformities

Evidence of trauma

Palpation Stepping and crepitus

Range of motion

Neurovascular function

Pain on active motion for 2 days

Erythema and swelling Flexion deformity Severe pain on passive extension

Infection Pyogenic Flexor Tenosynovitis Acute osteomyelitis Cellulitis Septic arthritis

Inflammation Systemic lupus erythematosus Rheumatoid Arthritis Gouty arthritis

Trauma Fracture Dislocation

X-rays: AP and lat. to rule out bony involvement or foreign body

MRI: Flexor tenosynovitis diagnosed by MRI of the hand is a strong predictor of early RA

Synovial Fluid Aspiration suppurative synovial fluid: culture

nonsuppurative conditions: synovial fluid may show ▪ nonbirefringent crystals (gout)

▪ birefringent crystals (calcium pyrophosphate deposition disease [CPPD] or pseudogout)

CBC WBC count not elevated in nonsuppurative

conditions

left shift is frequently present in acute processes

ESR elevated in acute or chronic infections and may serve

as a marker to follow resolution of an infection not elevated in nonsuppurative conditions.

Coagulation studies in anticoagulated patients or in patients with known

or suspected bleeding diathesis DIC:rare

rheumatologic factor : rule out RA

acid-fast bacilli and fungal cultures in patients with chronic or atypical presentation.

pathophysiologic state causing disruption of normal flexor tendon function

Cause Infection* secondary to acute or chronic inflammation as a result of

diabetes, overuse, or arthritis

Septic FT : the 4 Kanavel signs1) finger held in slight flexion2) fusiform swelling3) tenderness along the flexor tendon sheath4) pain with passive extension of the digit

orthopedic emergency closed-space infection increased pressure inhibits blood flow tendon ischemia tendon necrosis and rupture

Contiguous spread of infection- radial bursa- ulnar bursa- horseshoe abscess- midpalmar space- thenar space- Parona’s space

Finger stiffness Vascular occlusion Tendon necrosis and function loss Median nerve compression

Principles Antibiotics Rest, splint and elevation Drainage Rehabilitation

Conservative treatment- within 24-48 hours after onset- admission for empiric antibiotics and observation

- splint (position of safe immobilization)

- elevation

Surgical treatment- late presentation ( > 48 hours)- conservative treatment failure- abscess suspected : marked tenderness- immunocompromised

Incision and drainage with postoperative closed irrigation

modified Neviaser technique

postoperative closed irrigation- 30 ml of isotonic solution q 2 hours for 48

hours - re-examine : off or continue?

Rehabilitation- ASAP (alleviation of inflammation)- re-apply splint between exercise sessions

(for the first few days)

Incision hereor more!

Open drainage : advanced infection and necrosis that require debridement