Significance of early diagnosis and surgical management in treating Mycobacterium immunogenum-related pyogenic extensor tenosynovitis: a case report.

BACKGROUND: Non-tuberculous mycobacteria (NTM) are environmental organisms that are increasingly contributing to human infections. Mycobacterium immunogenum, a variant of NTM discovered in 2001, is a rapidly growing mycobacterium that exhibits multidrug resistance. Reports of infections caused by this organism, particularly tenosynovitis in the musculoskeletal system, are limited. CASE PRESENTATION: A 71-year-old female with vesicular pemphigus, undergoing immunosuppressive therapy, presented with a progressively enlarging tumour on the dorsum of her right hand, along with erythematous papules that extended across her right forearm. The specimens of skin tissues and blood cultures revealed the presence of M. immunogenum. Magnetic resonance imaging evaluation led to the diagnosis of pyogenic extensor tenosynovitis. A multidrug regimen, comprising amikacin and clarithromycin, was initiated, followed by synovectomy. The patient underwent a course of 180 days of antimicrobial therapy and demonstrated no signs of disease recurrence one year after treatment completion. CONCLUSION: Early diagnosis and surgical intervention are crucial to prevent the adverse prognostic implications of pyogenic extensor tenosynovitis caused by M. immunogenum. Effective management requires precise microbial identification and susceptibility testing, necessitating collaborative engagement with microbiological laboratories.

Arthroscopic suprapectoral biceps tenodesis provided earlier shoulder function restoration compared with open subpectoral biceps tenodesis during the recovery phase.

BACKGROUND: This study compared the clinical outcomes of open subpectoral biceps tenodesis and arthroscopic suprapectoral biceps tenodesis for symptomatic biceps tenosynovitis. Although both techniques have pros and cons, no studies have compared clinical and functional outcomes during the recovery phase. Previous studies show that suprapectoral tenodesis has a higher probability of Popeye deformity and postoperative bicipital pain and stiffness, whereas subpectoral tenodesis has a higher risk of nerve complications and wound infections. This study aimed for clinical comparison between arthroscopic suprapectoral biceps tenodesis and open subpectoral biceps tenodesis. METHODS: This study is a retrospective review of institutional records of patients with biceps tendinitis who underwent open or arthroscopic biceps tenodesis. Surgical indications included biceps tenosynovitis, biceps partial tear, and biceps pulley lesion. Patients with prior shoulder surgery, preoperative shoulder stiffness, or full-thickness tear of rotator cuff were excluded. Tenodesis was considered when the pain recurs within 3 months despite conservative treatment including at least 2 triamcinolone injections on the biceps tendon sheath. Visual analog scale (VAS) score for pain, presence of the night pain, American Shoulder and Elbow Surgeons (ASES) score, Constant score, and range of motion were assessed preoperatively at 3, 6, 12, and 24 months postoperatively and the last follow-up. RESULTS: A total of 72 patients (33 with arthroscopic suprapectoral biceps tenodeses and 39 with open subpectoral biceps tenodeses) were included in analysis. At postoperative 6 months, lower VAS score (0.4 ± 0.8 vs. 1.7 ± 1.9, P < .001), and the presence of the night pain (2 [6%] vs. 14 [36%], P = .002), ASES score (89.6 ± 9.2 vs. 81.4 ± 14.6, P = .006), and Constant score (89.4 ± 5.6 vs. 82.0 ± 12.5, P = .003) compared with the subpectoral group. The mean number of postoperative steroid injections for pain control in the subpectoral group (0.51 ± 0.80) was significantly higher than that in the suprapectoral group (0.18 ± 0.40) (P = .031). However, postoperative clinical outcomes were restored similar between the 2 groups at 12 months and the last follow-up. DISCUSSION: Arthroscopic suprapectoral biceps tenodesis performed statistically better than the subpectoral biceps tenodesis for the VAS, ASES, night pain, and Constant score at postoperative 6 months. However, only night pain and the Constant score showed differences that exceeded minimum clinically important difference during the recovery phase. At postoperative 12 and 24 months, biceps tenodesis provided satisfactory clinical outcomes and pain relief regardless of the fixation technique and suture anchor location.

Association of Patient-Reported Outcomes Measurement Information System Measures With Injection and Surgical Treatment Response in Patients With De Quervain Tenosynovitis.

PURPOSE: Treatment of de Quervain tenosynovitis is largely empiric. Patient-Reported Outcomes Management Information System (PROMIS) scores at the time of diagnosis might provide insights into the probability of success of nonsurgical management and predict the necessity for surgical treatment. We aimed to identify which, if any, of the PROMIS metrics may be used to identify patients who will opt for surgery or be managed with injection alone. METHODS: Patients presenting to a tertiary academic medical center from 2014 to 2019, with a sole diagnosis of de Quervain tenosynovitis, were identified and separated by initial and most invasive treatment of either injection or surgery. These groups were then dichotomized using cut points of more than one SD from the mean on the PROMIS physical function and pain interference scales, and a logistic regression model was used to determine the odds ratio of surgical intervention. RESULTS: Patients who had low physical function or high pain interference had significantly increased odds of ultimately undergoing surgery. Age ranging from 40 to 60 years and female sex were also associated with increased odds of undergoing surgery. CONCLUSIONS: Patients who scored lower than 40 for physical function or higher than 60 for pain interference had significantly increased odds of eventually undergoing surgical release for de Quervain tenosynovitis. PROMIS scores may identify patients who are likely to fail steroid injections as a sole nonsurgical intervention and inform an individualized discussion about surgical management of this condition. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Nontuberculous Mycobacterial Tenosynovitis of the Hand: A 10-Year Experience at Two Centers in South Korea.

Background: The aim of this study was to investigate the clinical characteristics of nontuberculous mycobacterial tenosynovitis and to report the process of diagnosis and the outcomes of surgical debridement and drug administration in South Korea. Methods: Between 2010 and 2019, 23 patients (10 men and 13 women) with nontuberculous tenosynovitis of the hand were treated at two centers. Their average age was 64 years, and the average duration of symptoms was 8 months (range, 1-36 months). Eight patients had a history of trauma or surgery. The average number of corticosteroid injections before diagnosis was 2.6 for 7 patients. All 23 patients were treated with a combination of extensive tenosynovectomy and antibiotics. Results: Of the 23 patients, 20 were available for the final follow-up (1, lost to follow-up; 1, transferred to another hospital; and 1, died from a comorbidity). The most common species was Mycobacterium intracellulare (70%), followed by Mycobacterium abscessus (10%). The frequency of involvement of the extensor/flexor tendon was similar to that of the wrist/finger. The mean number of surgical debridement operations was 2.2. The average duration of antibiotic administration was 9.8 months. At the last follow-up, 3 patients were symptom-free with full range of motion at the involved site, 1 patient complained of localized swelling or pain with full range of motion, 1 patient was found to have a recurrence of infection in a finger, and 15 complained of restricted joint motion. Conclusions: The most common species noted in patients with nontuberculous mycobacterial tenosynovitis was M. intracellulare. Patients with only 1 finger involved showed good range of motion at the final follow-up. Most patients experienced delayed wound healing and adverse effects from drug therapy during treatment and limited joint motion at the final follow-up.

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.

de Quervain's Tenosynovitis with Accessory Abductor Pollicis Longus Tendon and 'Wartenberg's syndrome' - A Case Report.

BACKGROUND: de Quervain's tenosynovitis (dQT) is focal soft-tissue rheumatism of abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons. The Swiss surgeon Fritz de Quervain first demonstrated the disorder in 1895. Anatomical variation of the first wrist extensor compartment, for example, accessory APL, can be associated with de Quervain's tenosynovitis. Sometimes, dQT may coexist with superficial radial nerve (SRN) compression, widely known as 'Wartenberg's syndrome'. CASE PRESENTATION: In the present case study, clinical features of de Quervain's tenosynovitis have been described in a 45-year-old housewife without any known risk factor for the disorder. The patient complained of pain and swelling on the radial aspect of dorsal wrist; there was local tenderness, and the Finkelstein test was positive. An ultrasonogram of the wrist's first extensor compartment depicted a thick, hypoechoic tenosynovial sheath encircling two APL and one EPB tendon. Swollen first extensor wrist compartment compressing the SRN led to tingling and dysesthesia, 'Wartenberg's syndrome.' CONCLUSION: de Quervain's tenosynovitis with accessory abductor pollicis longus tendon may present with 'Wartenberg's syndrome'.

De Quervain's tenosynovitis: a non-randomized two-armed study comparing ultrasound-guided steroid injection with surgical release.

PURPOSE: Ultrasonography is currently used for both diagnostic and therapeutic purposes in de Quervain's tenosynovitis. There is a dearth of information on how effective an ultrasound-guided (USG) steroid injection is when compared to surgical release of the first extensor compartment. Hence, we performed a non-randomized two-armed comparison study to test our hypothesis that USG guided steroid injection is equally effective as surgery. METHOD: 62 consecutive patients participated in the study with 32 of them selecting the option of USG guided injection (Set A), and the rest undergoing surgical release (Set B). We reviewed them after 3 and 6 weeks and 6 months for functional outcome using DASH, PRWE and VAS scores, recurrence, or any complications. They were further followed if they were symptomatic. RESULTS: The DASH/PRWE/VAS scores improved at the end of 6 months from 81.7/79.3/6.8 to 1.0/1.7/1.0, respectively for patients undergoing USG guided steroid injection. Similarly, for the patient undergoing surgery, the scores improved from 82.2/81.5/6.7 to 1.7/3.4/1.0, respectively. This was statistically significant in both the groups (p < 0.05) and was comparable to each other. Two patients in Set A came back with recurrence at eight and 10 months and two reported occasional pain on heavy work. Three patients had tenderness and two had numbness in Set B at the scar site. CONCLUSION: We observed that USG guided steroid injections are comparable to surgical release in terms of pain relief, functional outcome, complications.

Antibiotics Versus Surgery in Treatment of Early Flexor Tenosynovitis.

BACKGROUND: Treatment of pyogenic flexor tenosynovitis (FTS) historically involved surgical debridement supplemented with antibiotic therapy. No consensus exists on either: (1) the treatment algorithm for this infection; or (2) the clinical definition of "early" FTS. We performed a retrospective study to clarify indications for nonoperative management. METHODS: We identified 40 patients with a diagnosis of FTS using Current Procedural Terminology and International Classification of Diseases, Tenth Revision, codes and a keyword search from an electronic medical record between 2011 and 2019. Patients underwent either surgical management (SG) (n = 20) or early antibiotics only (EAG) (n = 20). The surgical group was divided into patients with intraoperative purulence within the tendon sheath (PU) and those without purulence (NP). RESULTS: The number of Kanavel signs and duration of days of symptoms were significantly greater in SG compared with EAG. Subgroup analysis of SG showed a greater number of days of symptoms in the NP group when compared with the PU group. No statistical significance was found with respect to age, smoking, or specific individual Kanavel signs between SG and EAG. CONCLUSIONS: Both duration of symptoms and number of Kanavel signs should be considered in suspected early FTS. Patients with shorter duration of symptoms and fewer Kanavel signs were treated successfully with antibiotics alone. Operatively confirmed FTS presented more acutely with fewer days of symptoms and a higher number of Kanavel signs. Patients with subacute presentations may represent inflammatory conditions and hand infections other than FTS.

Limited Flexor Sheath Incision and Drainage in the Emergency Department in the Management of Early Pyogenic Flexor Tenosynovitis.

BACKGROUND: Pyogenic flexor tenosynovitis (PFT) has been considered a surgical emergency. Varying operative approaches have been described, but there are limited data on the method, safety, and efficacy of nonoperative or bedside management. We present a case series where patients with early flexor tenosynovitis are managed using a limited flexor sheath incision and drainage (I&D) in the emergency department (ED) to both confirm purulence within the flexor sheath and as definitive treatment. METHODS: A retrospective study of all patients clinically diagnosed in the ED with flexor tenosynovitis at our institution from 2012 to 2019 was performed. Patients with frank purulence on examination were taken emergently to the operating room (OR). Patients with equivocal findings underwent limited flexor sheath I&D in the ED. Safety and efficacy were studied for patients with early flexor tenosynovitis managed with this treatment approach. RESULTS: Thirty-four patients met the inclusion criteria. Ten patients underwent direct OR I&D, and 24 patients underwent ED I&D. In the ED I&D group, 96% (24 of 25) of patients did not have frank purulence in the flexor sheath and were managed with bedside drainage alone. There were no procedural complications and no need for repeat operative intervention. Time to intervention (3.1 hours vs 8.4 hours) was significantly shorter for the ED I&D group compared with the OR I&D group. Within the ED I&D group, 86% of patients exhibited good/excellent functional scores. CONCLUSIONS: Limited flexor sheath I&D in the ED provides a potential safe and effective way to manage patients with early flexor tenosynovitis.

Diagnosis and outcome following tenoscopic surgery of the digital flexor tendon sheath in German sports and pleasure horses.

BACKGROUND: Digital flexor tendon sheath (DFTS) pathology is an important cause of lameness in horses. The outcome after surgical treatment is variable and depends on the exact diagnosis. OBJECTIVES: To (1) describe the prevalence of lesions associated with lameness caused by nonseptic DFTS tenosynovitis in a large population of German sports and pleasure horses; (2) determine the sensitivity and specificity of diagnostic imaging techniques for identifying lesions within the DFTS with tenoscopic diagnosis being the gold standard; (3) explore associations between tenoscopically diagnosed lesions and signalment, purpose, and limb affected; and (4) describe the outcome following DFTS tenoscopy with nonseptic DFTS tenosynovitis in this population. STUDY DESIGN: Retrospective case series. METHODS: Medical records of horses admitted for tenoscopic surgery of nonseptic DFTS tenosynovitis between 2011 and 2020 were reviewed. Follow-up information was obtained via telephone contact. Sensitivity and specificity of ultrasonography and contrast tenography were determined using tenoscopic diagnosis as gold standard and univariable analysis was used to explore associations between signalment, case history, and tenoscopic diagnosis. RESULTS: Medical records from 131 horses were retrieved, of which 8 horses had bilateral disease and 6 horses were presented for tenoscopy on two separate occasions (3 for tenoscopy in the same limb, 3 in a different limb), thus, making a total of 145 limbs. Lesions were most commonly diagnosed in the deep (DDFT; n = 55 limbs) and superficial (SDFT; n = 55 limbs) digital flexor tendons. Manica flexoria (MF) lesions were detected in 44 limbs and palmar/plantar annular ligament (PAL) constriction in 99 limbs. In 36 limbs, only one structure within the DFTS was injured, whereas in 109 limbs a combination of lesions was noted, the most common being the combination of a SDFT lesion with PAL constriction. All affected limbs were examined with diagnostic ultrasonography; contrast tenography was performed in 86 limbs. For diagnosis of MF and DDFT tears, tenography was more sensitive (89% [confidence interval, CI: 65.4%-95.2%]; 72% [CI: 46.4%-89.3%], respectively) than specific (64% [CI: 52.5%-77.6%]; 53% [CI: 42.2%-73.3%], respectively) whereas ultrasonography was more specific (92% [CI: 84.5%-96.3%]; 92% [CI: 83.6%-96.0%]) with lower sensitivity (64% [CI: 47.7%-77.2%]; 54% [CI: 39.5%-67.9%]). For SDFT lesions, ultrasonography was highly specific (94% [CI: 86.9%-97.9%]) with lower sensitivity (66% [CI: 51.3%-77.4%]). Follow-up information following first surgery was obtained for 118 horses (132 limbs): 18 (15.3%) of 118 horses remained chronically lame, 40 (33.8%) performed at a reduced level and 60 (50.8%) performed at the same or higher level following rehabilitation after tenoscopy. Horses with DDFT lesions had the poorest outcomes with only 36.6% returning to the same or higher level of exercise. MAIN LIMITATIONS: Retrospective analysis of clinical records and subjective outcome assessment based on owner follow-up with potential recall bias. Findings on diagnostic imaging are impacted by many factors including equipment quality and operator expertise and experience. CONCLUSION: Diagnostic imaging techniques were complimentary and contrast tenography was sensitive and ultrasonography was specific for the diagnosis of MF and DDFT lesions. Following tenoscopic surgery for nonseptic tenosynovitis of the DFTS, approximately half the cases were able to return to preinjury level of exercise.

Partial Resection of First Dorsal Compartment Extensor Retinaculum in De Quervain's Stenosing Tendovaginitis Release.

Various surgical techniques exist to treat de Quervain's stenosing tendovaginitis. Specific surgical techniques for de Quervain's are designed to avoid complications including injury to branches of the superficial branch of the radial nerve, inadequate decompression, reflex sympathetic dystrophy, and palmar subluxation of the released tendons. A simple dorsal incision through the extensor retinaculum is advocated by many as a means to release the compartment while preventing postoperative subluxation. A single incision through the retinaculum limits exposure of the compartment and could lead to reannealing of the retinaculum and recurrent symptoms. Partial resection of the extensor retinaculum provides a more complete release and has not been found to lead to palmar tendon subluxation.

A Retrospective Case Series Study on a Minimally Invasive Ultrasound-Guided First Dorsal Compartment Release Technique for Refractory De Quervain Tenosynovitis.

OBJECTIVE: The aim of this study was to evaluate the outcomes of patients treated with a novel minimally invasive complete release of the first dorsal compartment percutaneously under ultrasound guidance using an 18-gauge needle with an 18 blade at the tip. DESIGN: This was a retrospective case series. Nine adults (ten wrists) were included in the study of this technique. All patients had failed conservative care and had tenderness to palpation over the first dorsal compartment, a positive Finklestein test, and confirmed tenosynovitis with ultrasound imaging before the procedure. The main outcome measures were reduction in pain as determined by the numeric rating scale and improvement of function determined by the Nirschl Phase scale at both short- and long-term follow-up. RESULTS: There was 100% follow-up, with mean (SD) follow-up occurring at 23.1 (9.8) mos (range, 9-42 mos). From preprocedure to follow-up, numeric rating scale pain decreased from 4.1 (SD, 2.5) to 0.0 (SD, 0.0) ( P < 0.001), and Nirschl phase improved from 2.5 (SD, 1.9) to 0.2 (SD, 0.4) ( P = 0.03). No patients required revision open-release surgery or suffered neurovascular complications. CONCLUSION: This technique resulted in significant improvement of pain and function for all patients and no short- or long-term neurovascular complications were seen.

Spontaneous tendon rupture in a patient with systemic sclerosis: a case report.

BACKGROUND: Systemic sclerosis (SSc) is an incurable autoimmune disease characterized by progressive skin fibrosis and organ failure. Tenosynovitis is a common musculoskeletal manifestation, but tendon rupture has seldom reported in SSc. CASE PRESENTATION: We present a rare case of a 49-year-old female with SSc who has suffered from bilateral tendon rupture of the fourth and fifth digits with positive antinuclear antibody (ANA) and anti-centromere B antibody, but negative rheumatoid factor in serum. In the extensor tendons of the patient's hands, inflammation, edema, hypertrophy and tendon interruption were detected with ultrasound and magnetic resonance imaging(MRI). Tendon transfer repair surgery was performed and 10 mg/week methotrexate was then used in this patient. Her hand function was improved well with methotrexate and rehabilitation treatment postoperatively. CONCLUSIONS: Early detection of tenosynovitis is necessary to prevent tendon rupture in SSc patients. Ultrasound and Magnetic Resonance Imaging appear to be useful examinations for evaluating tendon pathology for early detection.

Progressive flexor tendon sheath infection on hand after needle puncture during surgery: a case report.

INTRODUCTION: Flexor tendon sheath infection may be due to trauma, laceration, or bites, commonly directly inoculating the sheath. Kanavel cardinal signs in flexor tendon sheath infection cases consist of symmetrical swelling of the entire digit, a digit with semi-flexed posture, exquisite tenderness along the course of the tendon sheath, and pain with attempted passive extension of the digit. Elevated levels of inflammation markers such as white blood cell count, erythrocyte sedimentation rate, and C-reactive protein are often found in such cases. Flexor tendon sheath infections require immediate diagnosis and treatment to prevent poor clinical outcomes. This paper reports one case of severe flexor tendon sheath infection with poor outcomes that required ray amputation of the affected finger. CASE PRESENTATION: A 35-year-old Sundanese male presented to the emergency department with right middle finger pain accompanied with swelling, blister, and blackened color 24 hours after accidental puncture by suture needle during gynecologic surgery. The patient was a resident physician of the obstetrics/gynecology department. The finger was necrotic with blisters at the proximal phalanx of the palmar aspect. Both the palmar and the dorsal aspects of the hand were swollen and inflamed, with firmer swelling on the dorsal part. The necrotic area had extended to the middle phalanx. The patient has been diagnosed with flexor tendon sheath infection with compartment syndrome. Immediate surgical debridement and fasciotomy with shoelace technique at the distal interphalangeal joint were performed. On the initial presentation, erythrocyte sedimentation rate, white blood cell count, and C-reactive protein were elevated. Smear culture was negative. A clear boundary of necrosis at the level of the middle phalanx of the right middle finger was found; subsequently, disarticulation at the level of the distal phalanx was performed. A ray amputation was performed to preserve the hand's function for performing surgeries in the future. CONCLUSION: Prompt diagnosis and treatment of flexor tendon sheath infection are required to prevent complications. Progressive inflammation around infected soft tissue due to untreated tenosynovitis may lead to poor outcomes and may lead to the amputation of the affected finger. This condition may occur even in medical professionals; as such, awareness for proper protection during any medical procedure and prompt treatment-seeking are encouraged.

Tenosynovitis with Psammomatous Calcifications Masquerading as Pyogenic Flexor Tenosynovitis.

We present a case report examining the clinical management of tenosynovitis with psammomatous calcifications presenting like pyogenic flexor tenosynovitis in a pregnant patient. Discussion details overlapping symptoms, important distinctions on imaging studies and the appropriateness of surgery. Level of Evidence: Level V (Therapeutic).

Stenosing tenosynovitis with rice bodies formation diagnosed by ultrasound: A case report.

RATIONALE: Rice bodies are usually found in several nonspecific chronic inflammatory diseases that are symptomatically dominated by primary disease and local compression symptoms. Rice bodies are usually detected by magnetic resonance imaging; however, some remote areas and areas with poor economic conditions do not have access to magnetic resonance imaging examination, which leads to delayed diagnosis of the disease. PATIENT CONCERNS: We report the case of a 62-year-old man with pain in the metacarpophalangeal joint of his right middle finger and limited flexion activity of his middle finger. DIAGNOSES: The mass was 1 cm, well-circumscribed, soft, and painless. Ultrasound showed stenosing tenosynovitis with rice body formation. INTERVENTIONS: The patient underwent tenosynovectomy with synovectomy of the right middle finger tendon sheath under plexus block anesthesia. OUTCOMES: No postoperative complications were noted. A 6-month follow-up showed no recurrence. The activity of the patient's middle finger improved significantly. LESSONS: Stenosing tenosynovitis with rice body formation is a very rare condition, and we use ultrasound for diagnosis. Ultrasound is convenient, rapid, inexpensive, and can obtain blood flow information, facilitate disease follow-up, and even allow ultrasound localization in advance for guided needle biopsy.

High-resolution ultrasound in the diagnosis of failed carpal tunnel decompression: a study of 35 cases.

We used high-resolution ultrasound to examine 35 median nerves (35 patients) with failed carpal tunnel decompression to identify the cause of failure. The carpal tunnel was examined before revision surgery, and the results were correlated with surgical findings. The cross-sectional area was measured, and nerve morphology was analysed at the sites of compression. We found persistent median nerve compression in 30 out of 35 patients. In 20 patients, the compression was caused by a residual transverse carpal ligament, in four by perineural fibrosis, in five by both of these causes and in one by tenosynovitis. In four patients, evidence of median nerve injury with an epineural/fascicular lesion was detected; and in one, no abnormalities were found. Surgical findings were consistent with the ultrasound findings except in one patient where tenosynovitis was associated with a giant cell tumour, which was missed by ultrasound. High-resolution ultrasound can provide helpful information in preoperative diagnosis of failed carpal tunnel decompression with good correlation between the ultrasound and surgical findings.Level of evidence: IV.

Tenosinovitis tuberculosa de tendones flexores de la mano. Caso clínico / Tuberculous tenosynovitis of flexor tendons of the hand. Case report

La tenosinovitis tuberculosa es una forma infrecuente de presentación de la tuberculosis extrapulmonar, de comportamiento crónico y usualmente confundida con otras enfermedades como la artritis reumatoide o el síndrome del túnel del carpo, entre otras. Es importante tener en cuenta el diagnóstico de tuberculosis en las tenosinovitis crónicas y no se debe descartar aunque no haya presencia de cuerpos de arroz. Describimos el proceso diagnóstico en una paciente que consultó por síntomas crónicos de dolor, edema y limitación funcional en la cara palmar de la mano derecha, sin cambios patológicos en la radiografía, pero con signos ecografícos de tenosinovitis. Describimos la evolucion clínica tras recibir tratamiento antituberculoso y realizar tenosinovectomia de los tendones flexores del 1°, 3° y 5° dedos. (AU)

Tuberculous tenosynovitis is an infrequent form of presentation of extrapulmonary tuberculosis, of chronic behavior and usually confused with other diseases such as rheumatoid arthritis or carpal tunnel syndrome, among others. It is important to take into account the diagnosis of tuberculosis in chronic tenosynovitis and it should not be ruled out in the absence of rice bodies. We describe the diagnostic process in a patient who consulted for chronic symptoms of pain, edema and functional limitation in the palmar aspect of the right hand without pathological changes on the radiograph, but with ultrasound signs of tenosynovitis. We describe the clinical evolution after receiving anti-tuberculosis treatment and performing tenosynovectomy of flexor tendons of the 1st, 3rd and 5th fingers. (AU)

Ultrasound diagnosis of pyogenic flexor tenosynovitis in a 9-month-old infant: a rare case report.

Pyogenic flexor tenosynovitis (PFT) is an aggressive infection of the flexor tendon sheath, requiring prompt intervention to minimize adverse outcomes. The diagnosis of pediatric PFT is often delayed due to the variable presence of Kanavel's signs in children and communication difficulties. A 9-month-old male presented to the emergency department with one of four Kanavel signs. The diagnosis of PFT was delayed until ultrasound was used to identify a fluid collection within the flexor tendon sheath. He was successfully treated with surgical debridement and antibiotic therapy, achieving full recovery by 6-month follow-up. This represents the youngest reported case of PFT. Difficulties with communication and physical exam as well as the variability of Kanavel's signs in young children can delay the diagnosis of pediatric PFT. Ultrasound can be a useful adjunct when clinical history and exam are equivocal, especially in children who present prior to language acquisition.