Pediatric flexor tenosynovitis and impetigo: an unusual association?

We describe the case of a child with impetigo in a typical facial distribution who went on to develop flexor tenosynovitis of the hand. The isolated organisms from cultures taken from the face and peri-operatively from the hand were the same (group A beta haemolytic Streptococcus), leading us to believe that there is an association between the conditions in our patient. Impetigo is a common childhood infection typically affecting the peri-oral region. The commonest pathogens are Streptococcus and Staphylococcus (Bernard, Curr Opin Infect Dis 21(2):122–128, 2008). Flexor tenosynovitis most frequently occurs after a breach in the skin on the volar aspect of the affected finger, permitting entry of organisms. If left untreated, this condition can result in significant destruction of the flexor mechanism and subsequent disability of the hand. Our patient made a good recovery following irrigation of the flexor sheath, intravenous antibiotics, and early post-operative physiotherapy. The association between impetigo and flexor tenosynovitis has not been previously made in the literature, and the clinical correlation is important in order to provide prompt and appropriate specialist treatment.     

Flexor tenosynovitis caused by Mycobacterium scrofulaceum: case report

Atypical hand infections with Mycobacterium species are uncommon, and Mycobacterium scrofulaceum infections are rare. We present a case of flexor tenosynovitis caused by M scrofulaceum in a 66-year-old man with hypertension and diabetes.     

Multiple unusual complications after extensive chronic sarcoid tenosynovitis of the hand: a case report

Sarcoidosis is an idiopathic disease characterized by multiple noncaseating granulomatous nodules. Involvement of the hand is extremely uncommon and tenosynovitis of the hand is rare. We present a patient who developed sarcoid tenosynovitis of multiple digits involving both the flexor and extensor tendons. He also developed flexor tendon rupture, subchondral bone erosions, and multiple joint subluxations.     

Acute gonococcal flexor tenosynovitis in an adolescent male with pharyngitis. A case report and literature review.

A 15-year-old boy had acute gonococcal flexor tenosynovitis of the middle finger associated with symptomatic gonococcal pharyngitis. The patient had a history of blunt trauma to the hand. The need for a careful history in any sexually active adolescent is emphasized. Acute flexor tenosynovitis may be the only manifestation of disseminated gonococcal infection.     

Sarcoid flexor tenosynovitis of the finger: a case report

A case report of flexor tenosynovitis of the right ring finger in a 27-year-old black woman leading to the diagnosis of sarcoidosis is presented. Sarcoidosis of a flexor tendon sheath is rare. Flexor tenosynovectomy provided material for histologic diagnosis and increased the function of the hand.     

Persistent spontaneous synovial drainage from digital flexor sheath in proliferative tenosynovitis: Two case reports and a review of the literature

Proliferative flexor tenosynovitis of the hand is an inflammatory process involving the synovial sheaths surrounding the tendons. It is most commonly caused by infection, but may also be caused by overuse, diabetes and rheumatic conditions such as rheumatoid arthritis and crystal arthropathies. The present report describes two patients with severe proliferative tenosynovitis, who developed a fistula between the tendon sheath and skin after instrumentation, resulting in persistent synovial drainage. After failing conservative management, both patients were managed with extensive flexor tenosynovectomy to prevent inoculation of bacteria into the flexor sheath. The presentation, management and outcome of each case is described in addition to a discussion of the literature on tenosynovial fistulas.     

Gouty tenosynovitis simulating an infection. A case report

Gouty tenosynovitis in the hand may be misdiagnosed as infectious or rheumatoid synovitis. Our case initially was treated as infectious tenosynovitis, but at reoperation gouty deposits were found penetrating the flexor tendon sheath. Tenosynovectomy and excision of intratendinous tophi were performed with a good result. Gouty synovitis is diagnosed in specimens fixed with ethanol because formalin destroys the typical crystals of urate.     

Candida albicans tenosynovitis of the hand

Invasive fungal infections of the hand are extremely rare and usually require an immunocompromised host. We report the first known case of Candida albicans tenosynovitis of the hand presenting as a mass in a boy with Buckley's immunodeficiency. Treatment was successful after radical synovectomy of both the flexor and extensor aspects of the hand after he failed to respond to combined amphotericin B and 5-fluorouracil therapy. Fungal tenosynovitis should be considered when swelling and decreased range of motion occur in the hands or digits of an immunocompromised host, especially if pain is not a prominent symptom.     

Acute nonspecific flexor tenosynovitis in the digits

Eight patients, aged 53 to 86 years (average, 63 years), with typical symptoms of acute infectious digital flexor tenosynovitis after excessive use of the hand were treated. No bacterial or crystal association was proven. In the two patients treated earliest, antibiotics were administered because of leucocytosis and a positive C-reactive protein (CRP) test result, but there was no improvement with this treatment. Surgical treatment relieved the symptoms in both these patients. In the other six patients, hand elevation and rest, as well as treatment with anti-inflammatory agents, resulted in complete resolution of the symptoms. Considering that the structure of the digital flexor tendon and the tendon sheath is similar to that of the synovial joint, the author suggests that the nonspecific tenosynovitis in this series could have been caused by overload on a flexor tendon system that had degenerated with age. Received: July 28, 2000 / Accepted: January 21, 2001     

The outpatient treatment of pyogenic flexor tenosynovitis

Historically, pyogenic flexor tenosynovitis has been treated with surgical debridement followed by hospitalization and administration of intravenous antibiotics. Recently, hand surgeons have treated this disorder on an outpatient basis. We retrospectively reviewed 37 patients with pyogenic flexor tenosynovitis who were managed as outpatients. Each patient underwent operative irrigation and debridement with intraoperative catheter irrigation. Postoperatively, patients were treated with outpatient intravenous antibiotics. Conversion to oral antibiotics was based on intraoperative culture results. Using this protocol, the average length of intravenous antibiotic usage was 3.5 days. Of the 28 patients with documented follow-up, 27 resolved the infection and one had a recurrence of the infection. No amputations were noted. Total active motion measurement was obtained from 15 patients showing good or excellent results in 14 of 15 patients. This preliminary retrospective case cohort suggests favorable results with outpatient treatment of pyogenic flexor tenosynovitis.     

Gouty flexor tenosynovitis mimicking infection: a case report emphasising the value of ultrasound in diagnosis

Tenosynovitis of the flexor tendons of the hand is a rare manifestation of gout. We present an unusual case of gouty tenosynovitis mimicking infection. The role of ultrasound in the management of this condition is emphasised.     

Die Sp��l-Saug-Drainage zur Behandlung von Infektionen der Beugesehnenscheide an der Hand

Objective

Treatment of pyogenic flexor tenosynovitis within the osteofibrous channel of the thumb and finger by insertion of a closed irrigation system.

Indications

Pyogenic tenosynovitis of the flexor tendons of the hand.

Contraindications

Necrosis of the flexor tendons or flexor tendon sheath, gangrene of the finger, extensive loss of soft tissue.

Surgical technique

Insertion of a flexible irrigation catheter via a guide wire into the flexor tendon sheath and a vacuum suction drain into the finger or the palm of the hand. Extensive exploration of the flexor tendon sheath is not mandatory.

Postoperative management

On days 0?C3 continuous irrigation, on day 4 change of the irrigation catheter to suction, on day 5 removal of the irrigation catheter, on day 6 removal of the suction drain, on day 7 start of exercise. Irrigation volume: about 500?C1500?ml/24?h isotonic solution.

Results

Of 35?patients treated for flexor tenosynovitis by closed irrigation, 33?were reviewed. There were 19?male patients and 14?female patients. The average age at the time of surgery was 51 (8?C85)?years. Hospital stay was 8.9 (3?C26)?days on average. At the time of follow-up, the average grip strength was 84% (23?C163%) of the unaffected side. Pain at rest was 0.2 (0?C4), pain during exercise 1.2 (0?C8) on the analogue scale, the DASH score was 16.8 (0?C58) points. According to the rating system for flexor tendon function, there were one poor, one fair, five good, and 26 excellent results.     

Digital flexion contracture and severe carpal tunnel syndrome due to tophaceus infiltration of wrist flexor tendon: first manifestation of gout

The authors report an unusual case of flexor tenosynovitis, severe carpal tunnel syndrome, and triggering at the carpal tunnel as the first manifestation of gout. A 69-year-old man presented with digital flexion contracture and severe carpal tunnel syndrome of his right hand and was treated surgically. A flexor tenosynovectomy and a median nerve neurolysis were performed through an extended carpal tunnel approach. The sublimis and the profundus tendons were involved. Partial ruptures and multiple whitish lesions suggestive of tophacceous infiltration of the flexor tendons were seen. Macroscopically, the removed synovial tissue was involved by multiple whitish nodules that were milimetric in size and was suggestive of monosodium urate crystals deposits. By light microscopy examination, numerous nonnecrotizing granulomas of different sizes were observed that were compounded by large aggregations of acellular nonpolarized material, surrounded by epithelioid histiocytes, mononuclear cells, and foreign body multinucleated giant cells. Postoperatively, the patient recovered with resolution of the median nerve symptoms and a near-to-full range of motion of the affected digits.To the authors' knowledge, this patient is the first case report with flexor tendons tophacceous infiltration as the first clinical sign of gout. Gouty flexor tenosynovitis can occur in the absence of a long history of gout. A high index of suspicion is paramount to the initiation of proper management. Operative treatment of gouty flexor tenosynovitis is mandatory to debulk tophaceous deposits, improve tendon gliding, and decompress nerves. Routine uric acid determination could be helpful in the preoperative evaluation of patients with flexor tenosynovitis.     

Tuberculous tenosynovitis of hand and wrist: a report of two cases

Tuberculous tenosynovitis of the wrist and hand is a rare condition that presents as chronic painless swelling, tenosynovitis and occasional compressive neuropathy. There is usually a striking lack of pulmonary symptoms. Two patients of tuberculous tenosynovitis of wrist and hand, who were managed at a tertiary health care centre, are presented. Both were young healthy adult males with isolated tenosynovitis of one hand each, without any associated systemic or pulmonary features. Both had been reviewed earlier at other tertiary referral centers without establishing the correct diagnosis. They presented with painful swelling in the wrist and palm. One patient also had features of ulnar nerve compressive neuropathy. Intra-operatively, both had thickened synovium of flexor tendons with "rice bodies" within the synovial fluid. Surgical management consisted of synovectomy and decompression of the nerves. Post-operatively, both were given full anti-tubercular treatment. On follow-up of over three years, they have remained free from recurrence. The slow progressive course of clinical symptoms and lack of radiological signs of tuberculosis leads to difficulties in establishing early diagnosis of this rare localized tuberculous infection. The functional outcome depends on early diagnosis and surgical intervention for symptomatic patients, thus emphasizing the importance of awareness of this rare entity.     

Tubercular flexor tenosynovitis due to mycobacterium bovis

Summary A 50 year old patient, butcher by occupation, diagnosed as tubercular flexor tenosynovitis of the right hand due to Mycobacterium bovis, a rare condition, is presented. Surgery combined with prolonged antitubercular chemotherapy was carried out and is also the recommended treatment.     

Cavernous haemangioma in the hand mimicking subacute tenosynovitis

A case of cavernous haemangioma arising from the superficial palmar arch is described. The initial symptoms were those of a subacute tenosynovitis. Surgical exploration showed that the tumor was not affecting the flexor tendons. It was completely resected and the patient had full recovery of hand function.     

Sesamoiditis of the index finger presenting as acute suppurative flexor tenosynovitis

Sesamoiditis involving the hand is uncommon, usually reported in the thumb, and has not been reported in the index finger. As rare as this clinical entity remains, its presentation simulating an acute suppurative flexor tenosynovitis is even more rare. We report a patient who presented with Kanavel's 4 cardinal signs of acute suppurative tenosynovitis who was subsequently found to have an acute sesamoiditis of the index finger. This finding was supplemented by a cadaveric and radiographic study to better delineate the anatomy of the index sesamoid and further explain the clinical presentation.     

Single side hole irrigation--a simple method of catheter irrigation of the tendon sheath

Treatment of septic flexor tenosynovitis at the hand requires significant hospital resources in terms of operative time and subsequent management of tendon irrigation. Delayed recovery or treatment failure may require re-irrigation and drainage. This may be due to failure to adequately irrigate the entire flexor sheath. We describe a method of closed tendon sheath irrigation which is simple to use and ensures that the complete tendon sheath is adequately irrigated. Unwieldy continuous irrigation is avoided and patient inconvenience is kept to a minimum.     

Acute flexor tenosynovitis caused by Streptococcus pneumoniae

A case of acute flexor tenosynovitis caused by Streptococcus pneumoniae in a previously well male truck driver is described. The importance of specimen collection and processing in establishing a microbiological diagnosis is emphasized. Early surgical drainage and treatment with penicillin resulted in rapid resolution of the infection and a return to full function of the hand.     

Mycobacterium marinum flexor tenosynovitis

Four culture-positive cases of flexor tenosynovitis of the hand caused by Mycobacterium marinum are reported. The organisms were cultured at 32 degrees. All patients were treated with a combination of flexor tenosynovectomy and antimycobacterial treatment with ethambutol and rifampin. The length of antimycobacterial treatment ranged from nine to 22 months. All four patients responded to treatment with cessation of signs of infection, increased range of motion, and complete wound healing.