Tuberculous tenosynovitis and ulnar bursitis of the wrist

Endoscopic Resection of Ulnar Bursa of the Palm: 2 Ulnar Portals Technique

Ulnar bursa of the hand invaginates the flexor digitorum superficialis and flexor digitorum profundus tendons of the little, ring, long, and index fingers. Distension of this bursa can have an inflammatory or infective cause. It can also originate from pathology of another site (e.g., degenerative wrist joint). Because of the tough overlying palmar aponeurosis, distended ulnar bursa can have swelling at a remote site. The distended ulnar bursa can also have compressive neuropathy to the ulnar nerve and median nerve. The purpose of this Technical Note is to describe the technical details of the 2 ulnar portals technique involving endoscopic resection of the ulnar bursa. This is indicated for symptomatic distension of the ulnar bursa, especially with hypothenar extension.

Clinical characteristics and treatment outcomes of tuberculous tenosynovitis of the hand and wrist

Objective: Vietnam is endemic with tuberculosis (TB), which is highly prevalent in the community. TB tenosynovitis of the wrist and hand is uncommon. Because of its insidious progression and atypical presentations, it is often difficult to diagnose, leading to treatment delays. This study investigates the characteristics of clinical and subclinical signs and treatment outcomes of patients with TB tenosynovitis in Vietnam. Patients and Methods: This prospective longitudinal cross-sectional study included 25 TB tenosynovitis patients in the Rheumatology Clinic at University Medical Center Ho Chi Minh City. The diagnosis was made based on a tuberculous cyst in histopathological specimens. The data were collected through medical history, physical examination, and medical records, including demographics, signs, symptoms, condition duration, and related laboratory tests and imaging. The outcomes of all participants were assessed after 12 months of treatment. Results: The most common symptom of TB tenosynovitis was swelling of the hand and wrist, which was present in all patients. Its other symptoms included mild pain and numbness of the hand in 72% and 24% of patients, respectively. It can affect any site on the hand. Hand ultrasound findings included thickening of the synovial membrane (80%), peritendinous effusion (64%), and soft tissue swelling (88%). Most patients (18/22) had a good outcome after the treatment with anti-tubercular drugs. Conclusions: TB tenosynovitis progression is often insidious. Its most common symptoms are swelling of the hand and mild pain. Ultrasound is a useful tool to support the diagnosis. A histological examination confirms the diagnosis. Most cases respond and have a good outcome after 9-12 months of anti-tuberculosis treatment.

Tuberculous flexor tenosynovitis of wrist and hand

A woman in her 40s presented with a swelling over her left distal forearm and hand since 7 months, progressively increasing in size. She had history of difficulty in moving her wrist and fingers with no associated pain. She had no immune or chronic conditions except for hypothyroidism for which she was on regular medication. On examination, there was an 8×7 cm swelling on the radial side of the volar surface of her left distal forearm extending till the thenar eminence. MRI of the left upper limb was suggestive of a soft tissue swelling arising from the flexor tendon.The patient was planned for surgical excision of the swelling. Intraoperatively, there was a mass arising from the flexor tendons of flexor digitorum superficialis, flexor digitorum profundus (FDP) and flexor pollicis longus (FPL), extending distally up to the mid palm region. On incising the flexor tendon sheath, it was observed that multiple yellowish rice like granules extended across the tendons. The lesion was excised completely and sent for histopathology examination. The lax FDP of little and ring fingers were plicated following proper tension adjustment and defect in FPL was primarily repaired. Postoperatively, the patient recovered well with no local wound complications. The biopsy report was suggestive of tuberculosis. The patient completed a course of antituberculosis treatment in 6 months.

Isolated multidrug-resistant tubercular tenosynovitis of the flexor tendon of the little finger

Isolated multidrug-resistant (MDR) tubercular tenosynovitis of the flexor tendons of finger without involvement of wrist is a rare presentation. Tenosynovitis of hand is an uncommon manifestation of extrapulmonary tuberculosis. Pyogenic flexor tenosynovitis of hand is frequently seen and is the closest differential. Non-specific clinical signs may lead to delay in diagnosis, which is often made after biopsy. Management includes surgical excision of necrotic tissue and infected synovium along with antitubercular therapy after histopathological diagnosis. MDR tuberculosis of hand is extremely rare and, to the best of our knowledge, has not been reported in the literature so far. We report an interesting case of MDR tubercular flexor tendon tenosynovitis of the little finger without any pulmonary involvement in an immunocompetent patient. The case was managed by complete synovectomy and second-line antitubercular therapy with complete resolution of disease and had no functional limitation.

Endoscopic Synovectomy of the Ulnar Bursa of the Palm of the Hand

Synovitis of the ulnar bursa is associated with tenosynovitis of the flexor tendons. Reported causes include suppurative or tuberculous infection, rheumatoid arthritis, and pigmented villonodular synovitis. Open synovectomy requires extensive soft-tissue dissection and may result in extensive scarring. The purpose of this Technical Note is to describe the technical details of endoscopic synovectomy of the ulnar bursa of the palm of the hand. This minimally invasive approach with small incisions allows aggressive postoperative hand therapy and avoids the complications of tendon adhesions, joint contractures, and hand stiffness.

Flexor Tenosynovitis of the Hand Caused by Mycobacterium tuberculosis

Infectious tenosynovitis of the hand is a serious condition with a high risk of morbidity. Mycobacterium tuberculosis is a rare cause of tenosynovitis, especially in regions where tuberculosis is no longer endemic, and presents significant diagnostic challenges. We present the case of a 42-year-old woman with no known history of or exposure to tuberculosis and a medical history of systemic lupus erythematosus on chronic immunosuppressive therapy who presented with swelling and erythema in the fifth finger of the left hand of 1-month duration. She underwent tenosynovectomy, and intraoperative cultures grew M tuberculosis. The patient completed an appropriate antibiotic regimen, and systemic workup revealed ring-enhancing lesions on brain MRI consistent with tuberculoma. We review the literature and current trends in the management of mycobacterial tenosynovitis, as well as the important teaching points of the case.

Flexor Tenosynovitis Due to Tuberculosis in Hand and Wrist: Is Tenosynovectomy Imperative?

The treatment of flexor tenosynovitis in the hand and wrist due to tuberculosis is controversial. Although some authors recommend the antituberculous chemotherapy, the others recommend the surgical treatment. In this article, 12 patients with synovial tuberculosis of the flexor aspect of the hand and the wrist were evaluated with respect to diagnosis and treatment modalities. None of the patients had a history of tuberculosis, concomitant disease, immunosuppressive drug use, drug abuse, and human immunodefficiency virus positivity. A chest x-ray and family screening were performed in all of the cases, none had evidence of tuberculosis in the lung. The biopsy, histopathological examination, acid-fast bacillus staining, and BACTEC tuberculosis culture were performed. Antituberculous chemotherapy was initiated in patients diagnosed with tuberculosis by either histological or microbiological examinations. The patients did not undergo any further surgery after biopsy procedures. The lesions regressed totally in all patients after 3 months of treatment. Carpal tunnel syndrome symptoms and signs recruited at five months of treatment. In patients with flexor tuberculosis tenosynovitis, it is possible to achieve good results by applying only medical therapy after a biopsy, and without the need for further surgery.

Tenosynovitis: a rare presentation of tuberculosis better known by hand surgeons than infectious diseases specialists

PURPOSE

Clinical presentation of tuberculosis is pleomorphic. Some forms are rare and better known by surgeons than infectious disease specialists.

METHODS

We describe a rare case of isolated chronic tenosynovitis of the wrist due to Mycobacterium tuberculosis in a 66-year-old man and review similar cases in the literature.

RESULTS

On literature search, only 23 other cases of tuberculous tenosynovitis were retrieved. Our case is similar, with an insidious classical presentation. The diagnosis was suggested at the surgical presentation by the presence of rice body masses.

CONCLUSION

The diagnosis of tuberculous tenosynovitis should be considered in chronic tenosynovitis. Functional prognosis may be committed without adequate treatment.

[Rare localization of tuberculosis: tenosynovitis of the fingers]

La ténosynovite tuberculeuse est une localisation rare de la tuberculose. Le diagnostic en est souvent tardif en raison de manifestations cliniques souvent pauvres et chroniques. Nous rapportons une observation de ténosynovite tuberculeuse du 2ème rayon de la main droite d’évolution favorable sous traitement antituberculeux.