23 year old male presents to your emergency department with left finger pain.  He states that the pain started approximately 3 days ago after attempting to inject IV heroin into the finger.  On physical exam the finger is diffusely swollen and tender to palpation.  The patient is holding the finger in the flexed position at rest and has severe pain with passive extension.  What is the appropriate treatment for this patient ?  (scroll down for the answer) 

A) Discharge home with splint. 

B) Discharge home with PO antibiotics.

C) Discharge home with PO antibiotics, hand surgery follow up next day. 

D) Admit for IV antibiotics. Consider surgical consult if no improvement. 

E) Emergent hand surgery consult in ED while starting IV antibiotics. 

The correct answer is E) Emergent hand surgery consult in ED while starting IV antibiotics.

With this patient’s presentation, flexor tenosynovitis should be high on your differential.  Flexor tenosynovitis is a true surgical emergency that requires emergent hand consultation in the ED and IV antibiotics. 

Flexor Tenosynovitis Pearls 

• Kanavel’s Criteria: tenderness along the flexor tendon, uniform/symmetric swelling of the finger, flexed posture of the finger, pain with passive extension 
• VIP to remember that all 4 signs are rarely present, especially early in course
• Staph aureus is the most common organism 
• Usually associated with penetrating trauma to the area
• Surgical Emergency - requires emergent surgical consult and IV antibiotics

Stapczynski, J. Stephan,, and Judith E. Tintinalli. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, N.Y.: McGraw-Hill Education LLC., 2011.