Flexor Tenosynovitis (Kanavel’s Signs)

Suppurative (infectious) flexor tenosynovitis is a medical emergency because the tendon sheath is a closed space and too much swelling can lead to compartment syndrome and necrosis.

* You can’t really get these complications in extensor tendons as it is an open space (no tendon sheath)

There are 4 cardinal signs of flexor tenosynovitis (Kanavel’s Signs)

  1. Tenderness along the whole tendon sheath (late sign)
  2. Finger held in flexion
  3. Fusiform swelling (sausage finger)
  4. Pain with passive extension *this is the earliest finding

It is usually caused by some sort of inoculation, but this can be something very small and the patient may not be aware that he/she had ever been injured (can also be caused by local or hematogenous spread). It’s not unreasonable to get an x-ray to rule out other things and if there’s a fever or they seem very unwell, you can do blood cultures. You also probably want to start the patient on some broad spectrum antibiotics such as vancomycin + ciprofloxacin (or ceftriaxone).

Treatment is tendon sheath drainage and debridement as well as antibiotics.

Glasgow Coma Scale (GCS)

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The Glasgow Coma Scale is a scoring system used to evaluate someone’s level of consciousness. It is scored out of 15 with 15 being totally awake and alert and 3 being totally not.

The important thing to remember is that the lowest score possible is 3.

Absolutely anything can score a 3, however if you are a living, breathing human being, hopefully you are scoring well up into the 10s.

Generally the GSC is applied in trauma situations and can be used as part of the decision making process of such thing things like should this patient be intubated?

  • ≥13 correlates with mild brain injury (or being ok)
  • 9-12 correlates with moderate injury
  • ≤8 represents severe brain injury – you should probably consider intubating them as they most likely cannot protect their airway
Thanks to Mike for the guest doodle!

Hand Exam: Motor 13/13 – Adductor Pollicis

Adductor Pollicis

  • Instruct the patient to do Froment’s sign – get the patient to forcibly grasp a piece of paper between the thumb and radial side of the index proximal phalanx
  • Origin:
    Oblique head: bases of 2nd and 3rd metacarpals, capitate and adjacent carpal bones
    Transverse head: anterior surface of body of 3rd metacarpal
  • Insertion: lateral side of base of proximal phalanx of thumb
  • Action: adducts thumb and flexes MP joint
  • Innervation: deep branch of the ulnar nerve

In a complete ulnar collateral ligament tear, the adductor pollicis can become entrapped between the remnants of the ligament

The 13 muscle groups you need to test in the hand exam:

  1. FPL
  2. FDP
  3. FDS
  4. Thenar muscles
  5. Interosseous
  6. Hypothenar muscles
  7. EPB and APL
  8. EPL
  9. EDC
  10. EIP and EDM
  11. ECRL and ECRB
  12. ECU
  13. Adductor Pollicis

Hand Exam: Motor 12/13 – Extensor Carpi Ulnaris (ECU)

Extensor Carpi Ulnaris (ECU)

  • Instruct the patient “Pull your hand up and out to the side”
  • Insertion: base of 5th metacarpal
  • Action: primarily ulnar deviation of the wrist, helps with wrist extension some too
  • Innervation: posterior interosseous branch of the radial nerve

Hand Exam: Motor 11/13 – Extensor Carpi Radialis Longus (ECRL) and Extensor Carpi Radialis Brevis (ECRB)

Extensor Carpi Radialis Longus (ECRL)

  • Instruct the patient “Make a fist and strongly bring your wrist back” and palpate over the tendons
  • Insertion: base of 2nd metacarpal
  • Action: radial deviation of wrist and some wrist extension too
  • Innervation: radial nerve

Extensor Carpi Radialis Brevis (ECRB)

  • Instruct the patient “Make a fist and strongly bring your wrist back” and palpate over the tendons
  • Insertion: base of 3rd metacarpal
  • Action: wrist extension (this is the major muscle for that)
  • Innervation: deep branch of radial nerve

The 13 muscle groups you need to test in the hand exam:

  1. FPL
  2. FDP
  3. FDS
  4. Thenar muscles
  5. Interosseous
  6. Hypothenar muscles
  7. EPB and APL
  8. EPL
  9. EDC
  10. EIP and EDM
  11. ECRL and ECRB
  12. ECU
  13. Adductor Pollicis

Hand Exam: Motor 10/13 – Extensor Indicis Proprius (EIP) and Extensor Digiti Minimi (EDM)

Extensor Indicis Proprius (EIP)

  • Instruct the patient “Point with your index finger with the rest of your hand in a fist”
  • Insertion: extensor hood of index finger
  • Action: extension of MCP joints and IP joints of the index finger
  • Innervation: posterior interosseous branch of radial nerve

Extensor Digiti Minimi (EDM)

  • Instruct the patient “Stick out your little finger with the other fingers in a fist”
  • Insertion: extensor expansion at the base of the proximal phalanx of the little finger
  • Action: extension of MCP joints and IP joints of the little finger
  • Innervation: posterior interosseous branch of radial nerve
Alternatively you can get the patient to ROCK ON!!!! (testing both EIP and EDM at the same time)

The 13 muscle groups you need to test in the hand exam:

  1. FPL
  2. FDP
  3. FDS
  4. Thenar muscles
  5. Interosseous
  6. Hypothenar muscles
  7. EPB and APL
  8. EPL
  9. EDC
  10. EIP and EDM
  11. ECRL and ECRB
  12. ECU
  13. Adductor Pollicis

Hand Exam: Motor 9/13 – Extensor Digitorum Communis (EDC)

Extensor Digitorum Communis (EDC)

  • Instruct the patient “Straighten your fingers”
  • Insertion: no direct bony attachment, instead has a funky extensor mechanism involving the central slip
    * The EDC to the small finger is absent in 50% of the population
  • Action: extension of MCP joints and IP joints (IP joints with the help of the intrinsic muscles)
  • Innervation: posterior interosseous branch of radial nerve

The 13 muscle groups you need to test in the hand exam:

  1. FPL
  2. FDP
  3. FDS
  4. Thenar muscles
  5. Interosseous
  6. Hypothenar muscles
  7. EPB and APL
  8. EPL
  9. EDC
  10. EIP and EDM
  11. ECRL and ECRB
  12. ECU
  13. Adductor Pollicis

Hand Exam: Motor 8/13 – Extensor Pollicis Longus (EPL)

 

EPL

Extensor Pollicis Longus (EPL)

  • Instruct the patient to lay their hand flat on a table and to “Lift only your thumb off the table”
  • Insertion: distal phalanx of thumb (first passes around Lister’s tubercle of the radius)
  • Action: extends thumb IP joint
  • Innervation: posterior interosseous branch of the radial nerve

The 13 muscle groups you need to test in the hand exam:

  1. FPL
  2. FDP
  3. FDS
  4. Thenar muscles
  5. Interosseous
  6. Hypothenar muscles
  7. EPB and APL
  8. EPL
  9. EDC
  10. EIP and EDM
  11. ECRL and ECRB
  12. ECU
  13. Adductor Pollicis


Hand Exam: Motor 7/13 – Extensor Pollicis Brevis (EPB) and Abductor Pollicis Longus (APL)

Thenar Muscles: Instruct the patient “Bring your thumb out to the side”
All supplied by posterior interosseous branch of the radial nerve 

Abductor Pollicis Longus (APL)

  • Insertion: base of the 1st metacarpal
  • Action: extension of the 1st metacarpal and helps with abduction
  • Innervation: posterior interosseous branch of the radial nerve

Extensor Pollicis Brevis (EPB)

  • Insertion: base of the proximal phalanx of thumb
  • Action: combines with EPL to extend thumb IP joint
  • Innervation: posterior interosseous branch of the radial nerve

The 13 muscle groups you need to test in the hand exam:

  1. FPL
  2. FDP
  3. FDS
  4. Thenar muscles
  5. Interosseous
  6. Hypothenar muscles
  7. EPB and APL
  8. EPL
  9. EDC
  10. EIP and EDM
  11. ECRL and ECRB
  12. ECU
  13. Adductor Pollicis

Hand Exam: Motor 6/13 – Hypothenar Muscles

Hypothenar Muscles: Instruct the patient “Bring your little finger away from the others”
All supplied by deep branch of ulnar nerve 

Abductor Digiti Minimi (ADM)

  • Origin: pisiform
  • Insertion: medial side of base of proximal phalanx of small finger
  • Action: abducts small finger, extends IP joints when MCP joint is stabilized
  • Innervation: deep branch of ulnar nerve

Flexor Digiti Minimi (FDM)

  • Origin: Flexor retinaculum and hook of the hamate
  • Insertion: medial side of base of proximal phalanx of small finger
  • Action: flexes MCP joint
  • Innervation: deep branch of ulnar nerve

Opponens Digiti Minimi (ODM) 

  • Origin: Flexor retinaculum and hook of the hamate
  • Insertion: medial border of 5th metacarpal
  • Action: rolls 5th metacarpal toward thumb, flexes 4th and 5th MCP joints for better thumb opposition
  • Innervation: deep branch of ulnar nerve

The 13 muscle groups you need to test in the hand exam:

  1. FPL
  2. FDP
  3. FDS
  4. Thenar muscles
  5. Interosseous
  6. Hypothenar muscles
  7. EPB and APL
  8. EPL
  9. EDC
  10. EIP and EDM
  11. ECRL and ECRB
  12. ECU
  13. Adductor Pollicis


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