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PubMed1986

An unusually aggressive Mycobacterium marinum hand infection.

An unusually aggressive Mycobacterium marinum infection of the hand that progressed despite surgical and medical treatment is presented. The infection progressed over a 3-week period after the patient had surgical treatment and received isoniazid (INH), rifampin, and ethambutol hydrochloride. The patient had a collar-button abscess, destruction of the metacarpophalangeal (MCP) joint capsule, flexor and extensor tenosynovitis, and metacarpal and proximal phalanx bone destruction at the MCP joint and metacarpal shaft. Although atypical mycobacterial infections of the hand are usually indolent but persistent, this Mycobacterium marinum hand infection progressed rapidly, even with surgical and medical treatment. A judgment was made to perform an index ray amputation. With a more complete excision of the infected tissue, there was a higher probability of controlling this severe infection. The patient was treated with antituberculosis medications for 6 months and is doing well 1 year after the operation.

Amputation, Surgical↗

PubMed1987

Median nerve compression at the wrist caused by a reversed palmaris longus muscle.

A case of median nerve compression at the wrist caused by a reversed palmaris longus muscle is described. Symptoms included paresthesias in the median nerve distribution and swelling on the flexor aspect of the wrist resembling tenosynovitis. The patient was a 13-year old girl, which we believe is the youngest recorded case in the literature.

Adolescent↗

PubMed1997

Treatment of flexor tendon sheath ganglions using ultrasound imaging.

Forty-one patients with a symptomatic digital mass or swelling of suspected ganglionic origin were examined by ultrasound. Findings were classified into 4 groups: group 1, solitary cyst appearing as a well-defined solitary oval anechoic mass (27 digits); group 2, multiple cysts having multiple oval anechoic masses (3 digits); group 3, solid tumor indicating a heterogeneous hypoechoic mass (6 digits); and group 4, tenosynovitis with no abnormal echoic mass (5 digits). Treatment was determined by lesion classification. In group 1, 26 of the 27 solitary cysts were punctured, and a jellylike material was aspirated from 24 cysts. Postaspiration ultrasound examination revealed that a cyst was still present in 2 cases, and these were excised surgically. In group 2, all the cysts were surgically removed. A ganglion with multiple cysts was confirmed on pathological examination. In group 3, the lesions were removed surgically; among the diagnoses were tendon sheath ganglion, giant-cell tumor of tendon sheath, neurilemmoma, and hemangioma. In group 4, no abnormal masses had appeared at follow-up examination. The 24 patients whose ganglions were treated by aspiration, as well as the 8 patients whose ganglions were excised, were monitored for more than 12 months. None of these 32 patients experienced residual pain or lesion recurrence. These results indicate that ultrasound is useful, in cases in which flexor tendon sheath ganglion are suspected, for assisting in diagnosis and determining whether patients should undergo aspiration or surgical excision.

Adolescent↗

PubMed1997

Imaging of the hand: degeneration, impingement and overuse.

Degenerative and overuse diseases as well as impingement syndromes of the hand are illustrated and discussed in this review article. Osteoarthritis of the interphalangeal joints as described by Heberden and Bouchard is a ubiquitous articular disease often associated with synovitis and erosive joint destruction. Osteoarthritis of the trapeziometacarpal joint is classified into four stages for proper indication of operation. Overuse can result in stenosing tenosynovitis around the wrist and in synovitis with or without impingement of the flexor or extensor tendons of the digitis or ruptures of the annular and cruciform pulleys. Although diagnosis of these entities is usually made by history and clinical investigation, ultrasound and MRI can be helpful tools in imaging of these diseases. Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) are the characteristic degeneration pattern of the wrist and represent the degeneration mechanisms in scapholunate insufficiency and nonunion of the scaphoid. SLAC wrist is a gradual degeneration classified in three stages and found in posttraumatic scapholunate rupture, calcium pyrophosphate dehydrate deposition disease (CPPD), rheumatoid arthritis, neuropathic diseases, trauma, and beta 2-microglobulin associated amyloid deposition. Ulna impaction syndrome is increasingly recognized as a cause of ulnar sided pain and exhibits a characteristic MRI appearance.

Cumulative Trauma Disorders↗

PubMed1997

Overload syndromes of the peritalar region.

INTRODUCTION: The purpose of this study was to identify the diagnostic possibilities of the different diagnostic techniques in the evaluation of the pathological conditions affecting the peritalar region. MATERIALS AND METHODS: Between September 1995 and December 1996, 58 patients, with a painful syndrome at peritalar level were submitted to MRI, which was performed using a 'dedicated system' consisting of 0.2 and 0.5 T equipment. Spin-Echo T1-weighted and Gradient-Echo T2-weighted sequences were used on sagittal, coronal and axial planes, with slice thickness of 3-5 mm. Conventional radiography was previously performed in all patients, while 18 of them underwent CT. Surgery or arthroscopy was performed in 22 cases. 36 patients underwent clinical follow-up associated with conventional radiography in six cases, MRI in 11 and to both of them in six patients. RESULTS: After arthroscopy and surgery, an involvement of the tibio-talar joint was found (one pathogenic synovial plica, three meniscoid syndrome and 12 anterior impingement) in 16 patients. Concerning the subtalar joint, surgical examination revealed a cellulo-adipostis of the sinus tarsi in two patients, while in three cases osteochondral damage of the subtalar joint was identified. In the last patient, degenerative changes of the posterior tibial tendon associated with osteochondral pathology of the talo-navicular joint were found. MRI findings agreed with the surgical and arthroscopic ones in all patients except for the synovial plica; in this case, the MRI was negative. Follow-up performed on 36 patients revealed 12 tibio-talar joint, 17 subtalar joint and 7 talo-navicular joint pathological conditions. DISCUSSION: Concerning the tibio-talar joint, MRI findings were confirmed by arthroscopy in all cases of anterior impingement. Magnetic resonance (MR), due to its capability in detecting osteochondral damage and identifying osteophyte sites, results in the best imaging method for evaluating this condition. Meniscoid syndrome is easily detected by MRI only in the presence of sufficient scar tissue, while conventional radiography reveals the calcific stage. In sinus tarsi syndrome, the ligamentous damage associated with sero-hemorrhagic effusion at fatty tissue level may lead to a 'chopping' effect on the nerve endings: this condition is well demonstrated by MRI. In all cases of osteochondral alterations affecting both the subtalar and talo-navicular joint, it has been possible to obtain correct diagnosis with MRI, which also depicted well the tenosynovitis of the posterior tibial tendon. In cases of stress fracture of the navicular bone, both CT and MRI demonstrated the lesions well, even when, in the early phases, conventional radiography produced a negative result. In conclusion, MRI may be considered the choice method in the study of different pathological alterations affecting the peritalar region, also providing detailed information useful for a therapeutic approach.

Adult↗

PubMed1998

The clinical features of rheumatoid arthritis.

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by progressive damage of synovial-lined joints and variable extra-articular manifestations. Tendon and bursal involvement are frequent and often clinically dominant in early disease. RA can affect any joint, but it is usually found in metacarpophalangeal, proximal interphalangeal and metatarsophalangeal joints, as well as in the wrists and knee. Articular and periarticular manifestations include joint swelling and tenderness to palpation, with morning stiffness and severe motion impairment in the involved joints. The clinical presentation of RA varies, but an insidious onset of pain with symmetric swelling of small joints is the most frequent finding. RA onset is acute or subacute in about 25% of patients, but its patterns of presentation also include palindromic onset, monoarticular presentation (both slow and acute forms), extra-articular synovitis (tenosynovitis, bursitis), polymyalgic-like onset, and general symptoms (malaise, fatigue, weight loss, fever). The palindromic onset is characterized by recurrent episodes of oligoarthritis with no residual radiologic damage, while the polymyalgic-like onset may be clinically indistinguishable from polymyalgia rheumatica in elderly subjects. RA is characteristically a symmetric erosive disease. Although any joint, including the cricoarytenoid joint, can be affected, the distal interphalangeal, the sacroiliac, and the lumbar spine joints are rarely involved. The clinical features of synovitis are particularly apparent in the morning. Morning stiffness in and around the joints, lasting at least 1 h before maximal improvement is a typical sign of RA. It is a subjective sign and the patient needs to be carefully informed as to the difference between pain and stiffness. Morning stiffness duration is related to disease activity. Hand involvement is the typical early manifestation of rheumatoid arthritis. Synovitis involving the metacarpophalangeal, proximal interphalangeal and wrist joints causes a characteristic tender swelling on palpation with early severe motion impairment and no radiologic evidence of bone damage. Fatigue, feveret, weight loss, and malaise are frequent clinical signs which can be associated with variable manifestations of extra-articular involvement such as rheumatoid nodules, vasculitis, hematologic abnormalities, Felty's syndrome, and visceral involvement. Although there is no laboratory test to exclude or prove the diagnosis of rheumatoid arthritis, several laboratory abnormalities can be detected. Abnormal values of the tests for evaluation of systemic inflammation are the most typical humoral features of RA. These include: erythrocyte sedimentation rate, acute phase proteins and plasma viscosity. Erythrocyte sedimentation rate and C-reactive protein provide the best information about the acute phase response. The C-reactive protein is strictly correlated with clinical assessment and radiographic changes. Plain film radiography is the standard investigation to assess the extent of anatomic changes in rheumatoid arthritis patients. The radiographic features of the hand joints in early disease are characterized by soft tissue swelling and mild juxtaarticular osteoporosis. In the the past 10 years, ultrasonography has gained acceptance for studying joint, tendon and bursal involvement in RA. It may improve the early clinical assessment and the follow-up of these patients, showing such details as synovial thickening even within finger joints. Other imaging techniques, such as magnetic resonance, computed tomography and scintigraphy may provide useful information about both the features and the extent for anatomic damage in selected rheumatoid arthritis patients. The natural history of the disease is poorly defined; its clinical course is fluctuating and the prognosis unpredictable. RA is an epidemiologically relevant cause of disability. An adequate early treatment of RA may alter the diseas

Arthritis, Rheumatoid↗

PubMedDate not supplied

The carpal tunnel syndrome.

Chronic carpal tunnel syndrome was initially described by James Jackson Putnam in 1880. A number of medical luminaries have also contributed to our understanding of the syndrome, including Paget, Marie, Ramsay Hunt, Phalen. and Osler. Carpal tunnel syndrome is the most common peripheral compression neuropathy. Most cases are idiopathic, with nonspecific tenosynovitis leading to median nerve compression. A number of diseases and other conditions are also associated with chronic carpal tunnel. Patients characteristically complain of nocturnal paresthesias or burning pain. Motor complaints relate to thenar muscular weakness and atrophy. Bedside diagnostic tests include Tinel's and Phalen's signs, and application of pressure over the median nerve by inflating a sphygmomanometer over the wrist. Tinel's sign is the induction of paresthesias by tapping over the site of the median nerve at the wrist. In Phalen's sign, symptoms are reproduced by maximum flexion of the wrist for 60 s. The classically described patients are middle-aged women. In addition, another distinct population is receiving increased attention, the relatively young male and female workers who experience symptoms performing repetitive manual labor.

Adult↗

PubMed1993

Spontaneous ruptures of flexor tendons secondary to extreme DISI deformity of the lunate in a rheumatoid wrist. A case report.

Spontaneous flexor tendon ruptures in rheumatoid arthritis are associated with flexor tenosynovitis and/or with attrition due to bony prominences in the carpal tunnel. The commonest bony prominence observed is the distal pole of a rotated scaphoid. We are reporting the case of an eighty-year-old woman with long-standing rheumatoid arthritis who presented with the inability to actively flex both the interphalangeal and the metacarpophalangeal joints of the right index finger, with preservation of passive motion. There was also loss of active flexion of the interphalangeal joint of the right thumb. Roentgenograms revealed a marked dorsal intercalated segment instability (DISI) pattern in both wrists associated with advanced joint destruction and collapse. Surgical exploration revealed total rupture of the FDS and FDP of the index finger and of the FPL, as well as partial rupture of the flexor tendons of the long finger. Rupture of the FPL was found to be due to attrition on the relatively common finding of a prominent and malrotated scaphoid. Ruptures of the flexor tendons of the index and long fingers appeared to be caused by a markedly prominent palmar protrusion of the lunate. Surgical repair was undertaken, including correction of the DISI deformity and reconstruction of carpal height by radiolunate fusion from a palmar approach. In addition the tubercle of the scaphoid was resected, and the FDS tendon of the ring finger was transferred to the distal stump of the FDP of the index finger; the FPL tendon was not reconstructed as arthrodesis of the interphalangeal joint of the thumb was planned at a later date.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

PubMed1990

[Amyloid arthropathy of the hand in patients on chronic hemodialysis].

Among 70 patients treated by hemodialysis for renal failure and operated for carpal tunnel syndromes, 17 presented with bone and joint lesions. Seven of them had destructive arthropathies of the distal interphalangeal joint, bilateral in 6 cases. Two radiological stages are described. Radiolucent lesions of the carpal bones were present in all the patients ("carpal amyloidosis"). The most frequent sites were around the radius-scaphoid-lunate and scaphoid-lunate joint spaces. Scaphoid-trapezoid-trapezium arthropathy was frequent with dynamic instability in one case. One patient had a pathological fracture of the lunate and scaphoid. Carpal tunnel syndrome was associated in all cases and dorsal wrist tenosynovitis in three cases. Amyloid arthropathy is more frequent in old patients on long-term hemodialysis. Amyloid deposits were shown in tendinous and joint synovial biopsy. The pathogenesis of amyloidosis is discussed.

Aged↗

PubMed1994

[Double tunnel syndrome of the upper limb in tophaceous gout. Apropos of a case].

Association of two tunnel syndromes secondary to tophaceous gout is uncommon. This article presents a case of ulnar and carpal tunnel compression. It concerns a 71 year old man with gout and treated for that condition. He presented with paraesthesiae in the fingers and loss of muscular strength in right hand. Physical examination discovered two masses, one in the epitrochlear groove, the other in the olecranon bursa; a severe ulnar palsy and a carpal tunnel syndrome. Neurolysis of both ulnar and median nerves was performed. After 2 years follow-up, paraesthesiae disappeared but atrophy of ulnar intrinsic muscles remained unchanged. The literature is reviewed. Carpal tunnel syndrome is well known in gout (28 reported cases), and is secondary to gouty tenosynovitis. Ulnar tunnel syndrome has been described once by Akizuki in 1984. The combination of the two conditions has not been previously been reported. In our case, median nerve compression was secondary to gouty synovitis but also to a bulky tophus from the floor of the carpal tunnel.

Aged↗

PubMed1986

[Carpal tunnel syndrome in childhood. Apropos of a familial and idiopathic case].

The authors report an uncommon' case of carpal tunnel syndrome in a ten year old girl. Symptoms are typical with noctural paresthesias. The nerve conductor studies show a important compression with thenar atrophy. In consideration of the importance of nocturnal pain and amyotrophy an operation was decided. At operation, the median nerve is found constricted under tickened transverse carpal ligament. At the wrist, the volume of nerve is normal, there are not anomalous muscles or inflammatory tenosynovitis. In fact, the appearance of median nerve is identical to the cases of carpal tunnel syndrome in adult. After surgery symptomsare abolished. The mother of the young girl, 37 year old, also present a bilateral carpal tunnel syndrome with onset at the age of 10 years. There is a important thenar atrophy. At operation, the nerve is very constricted with a tickened transverse carpal ligament; no other anomaly is noted. A study of literature complete these observations.

Adult↗

PubMed1998

[Sea urchin sting synovitis. Report of 4 cases].

Accidental sea urchin stings do not usually have any pathological consequences. However, cutaneous, synovial or toxic diseases can develop in some predisposed subjects, or under predisposing circumstances. The diagnosis, sometimes very delayed, can be difficult. Four personal cases of reactive arthritis or tenosynovitis, three of which affected the hand, are reported. All patients were cured after one or several surgical excisions. Antibiotics were not effective. The main clinical presentations, particularly delayed synovitis, are described. The various pathogenic hypotheses are in favour of an immunological reaction to the envelope protein of the sea urchin spikes.

Adolescent↗

PubMed2000

Ultrasound of the ankle and foot.

Ultrasound is an excellent tool for evaluating common ankle problems. it is more economical than MRI and its real-time nature helps in correlating the study with the symptomatic area. US can be used in ankle to evaluate tendons (including tears, tendinitis and tenosynovitis), joints, plantar fascia, ligaments, soft tissue masses, ganglion cysts, Morton's neuroma, and to look for foreign bodies. Power Doppler can be used to evaluate blood flow in acute inflammatory process and in reflex sympathetic dystrophy.

Achilles Tendon↗

PubMed2002

Flexor hallucis longus dysfunction: an overview.

Whereas acute and chronic injuries of the tibialis posterior, peroneal and Achilles tendon are frequently encountered, disorders of the flexor hallucis longus tendon are often overlooked, which may contribute to chronic pain and disability. Patients with stenosing tenosynovitis of the flexor hallucis longus tendon frequently present with overlapping signs and symptoms of flexor hallucis longus tendinitis, plantar fasciitis and tarsal tunnel syndrome, which the authors collectively refer to as "flexor hallucis longus dysfunction." A keen awareness of the presenting signs and symptoms and use of ancillary MR imaging and FHL tenography will assist the practitioner in recognizing this commonly misdiagnosed condition.

Ankle↗

PubMedDate not supplied

Peritendinous lesions: the role of high-resolution ultrasonography.

PURPOSE: To evaluate the peritendinous lesions over the extremities by high-resolution ultrasonography (HRUS). MATERIALS AND METHODS: The authors retrospectively collected 328 cases, focusing on peritendinous lesions in limbs. The diagnosis was made by US findings with long-term follow-up, aspiration and biopsy proved. RESULTS: The most common disease entity in our study is ganglion (n=270), followed by Baker's cyst (n=24). Other disease entities included tenosynovitis, bursitis, gout, hematoma, amyloidosis, thrombophlebitis, and other tumor/tumor-like lesions, such as osteogenic sarcoma (OGS), schwannoma, lymphoma, myxoid lipomsarcoma, xanthoma, intramuscular cavernous hemangioma, pigmented villonodular synovitis (PVNS), giant cell tumor of the tendon sheath (GCTTS), etc. CONCLUSION: Because of dynamic capabilities and aid of real-time sono-guided fine needle aspiration, HRUS becomes an efficient and inexpensive tool for musculoskeletal lesions, especially in the superficial parts.

Adult↗

PubMed2001

Four cases of tendinopathy in patients on statin therapy.

During the last decade, statins have been widely prescribed as lipid-lowering drugs. Their overall safety profile is good. The main musculoskeletal side effects have consisted of muscle pain and weakness, peripheral neuropathy, and a few cases of drug-induced lupus. We report the first four cases of tendinopathy in patients receiving statin therapy. There were three men and one woman. The diagnoses were extensortenosynovitis at the hands (case 1), tenosynovitis of the tibialis anterior tendon (case 2), and Achilles tendinopathy (cases 3 and 4). Two patients were on simvastatin and two on atorvastatin. The tendinopathy developed 1 to 2 months after treatment initiation. The outcome was consistently favorable within 1 to 2 months after discontinuation of the drug. Similar cases have been reported to French pharmacovigilance centers. This report of four cases of tendinopathy draws attention to a possible and heretofore unrecognized side effect of a drug class that is becoming increasingly popular. Statins are effective in lowering high cholesterol levels in patients with type IIa or IIb hypercholesterolemia. They have been widely used for the last decade, particularly in the secondary and primary prevention of major coronary events. Statins act by inhibiting the enzyme hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase. Although most patients tolerate statins extremely well, a few experience side effects requiring treatment discontinuation. Reported musculoskeletal side effects include myalgia and a few cases of rhabdomyolysis and polymyositis. Induced lupus and peripheral neuropathy are exceedingly rare.

Acute Disease↗

PubMed2001

Atypical mycobacterial infections of the hand: report of eight cases and literature review.

INTRODUCTION: Atypical mycobacteria are an uncommon cause of hand infections in immunocompetent patients. Diagnosis is often delayed, with consequent increased morbidity. Better awareness would allow earlier diagnosis and treatment. MATERIAL AND METHODS: Eight patients with atypical mycobacterial hand infections treated in our department over a 21 year period have been retrospectively identified. Their charts have been searched for the general characteristics of these infections, treatment and outcome. Our findings have been compared to the data collected from a literature review. RESULTS: These pathogens have caused soft tissue infections in otherwise healthy patients. Clinical signs were those of chronic finger or wrist synovitis or skin granulomas. Carpal tunnel syndrome was a common finding. Diagnosis relied on surgical biopsy. Germ identification required specific incubation temperature and media. Antibiotics and synovectomy have been the mainstay of therapy. DISCUSSION: In a patient with achronic, relapsing, superficial or deep skin infection or tenosynovitis, aquatic and farm exposures are important anamnestic keys to diagnosis. Extensive synovectomy is both diagnostic and therapeutic. Specific cultures should be ordered without delay. Oral pharmacotherapy should be initiated upon clinical suspicion.

Adult↗

PubMed2003

Regional musculoskeletal conditions: pain in the forearm, wrist and hand.

Pain in the forearm, wrist or hand may arise from one of several discrete rheumatic disorders of soft tissues, such as tenosynovitis, or from a non-specific regional pain syndrome. Symptoms are prevalent in the general population and both patterns of illness are well represented. Many epidemiological investigations of prevalence, incidence, causal risk factors, management and prevention exist, although surveys have used a wide variety of case definitions, hampering comparisons. Improved standardized approaches to classification are in prospect and these are described. A synthesis is also attempted of the main findings of existing surveys. A growing body of evidence now links distal arm pain with physical risk factors in the workplace (e.g. repetition, force, duration, short cycle time and awkwardness of posture); some possible ergonomic solutions to occupational arm pain are discussed. But occupational and psychosocial factors are also linked with symptom reporting and disability, and their role in pathogenesis may be important in primary prevention and the management of recalcitrant cases. Some key research questions are proposed aimed at preventing chronicity and disablement from arm pain.

Forearm↗