MRI of musculoskeletal extraspinal tuberculosis

PURPOSE

The aim of this study was to describe the MR findings in extraspinal musculoskeletal tuberculosis (EMT).

METHOD

A retrospective review was conducted of the MR findings of 18 patients with microbiologically and/or pathologically proven EMT. All MR studies were performed using T1-and T2-weighted spin echo sequences. T1-weighted spin echo sequences after Gd-DTPA injection were obtained for 12 patients. The MR images were evaluated for abnormalities in joints, bones, and soft tissues, and the results were grouped by anatomic localization, frequency distribution of structures affected, and morphologic patterns of involvement.

RESULTS

Isolated soft tissue tuberculosis was found in 10 (55.5%) patients and involvement of more than one structure in 8 (44.4%). Pyomyositis (n = 6) and arthritis with involvement of adjacent soft tissues (n = 7) were the most common forms of presentation. One patient presented with isolated fascial superficial tissue involvement in one leg. Isolated pyomyositis involving one (n = 3) or two (n = 3) muscles was homogeneous in six cases and showed intermediate (n = 6), low (n = 2), or high (n = 1) signal intensity on T1-weighted images and a high and very hyperintense signal on T2-weighted images. The tenosynovitis synovial fluid was homogeneous (n = 1) or heterogeneous with multiple tiny hypointense nodules (n = 1) on T2-weighted images. The subdeltoid bursitis fluid was characterized by homogeneous low signal intensity with a hyperintense rim (n = 2) on T1-weighted images and homogeneous (n = 1) or heterogeneous hyperintense signals with areas of low signal intensity (n = 1) on T2-weighted images. In tuberculous arthritis, the synovial joint fluid (n = 7) showed heterogeneous (n = 4) or homogeneous (n = 3) low signal intensity on T1-weighted images and high or very high signal intensity on T2-weighted images. Where involved, the adjacent muscle(s) (n = 8) were usually hypointense on T1-weighted images and very hyperintense on T2-weighted images. Associated cellulitis was found in arthritis with involvement of neighboring soft tissues (n = 5), pyomyositis (n = 2), and tenosynovitis (n = 1). The images obtained after Gd-DTPA showed peripheral (n = 10) or heterogeneous (n = 1) enhancement or no enhancement (n = 1).

CONCLUSION

The MR findings for EMT are variable. Although diagnosis is dependent largely on prior presumption and clinical context, MRI provides valuable guidelines in defining the extent of the lesions to select the appropriate treatment and for follow-up of abnormalities.

Tenosynovitis of the posterior tibial tendon

PTT tenosynovitis is a recognized entity no longer confused with an ankle sprain. Three possible causes are (1) overuse or age related (mechanical in cause, true stage I disease), (2) seronegative spondyloarthropathies (clinical suspicion, hematologic analysis), and (3) rheumatoid arthritis (deformity may be owing to ligamentous or capsular destruction). The PTT has a hypovascular zone 40 mm proximal to the insertion of the tendon and 14 mm in length. Pain often is localized to this portion of the tendon (primarily in stage I disease). Ultrasound is an inexpensive and accurate method to assist in the diagnosis of this condition and may replace MR imaging as more experienced ultrasonographers appear. The initial management of PTT tenosynovitis includes tendon rest and nonsteroidal anti-inflammatory medication and physical therapy. Surgical synovial débridement is performed early (6 weeks) in patients with enthesopathies (seronegative disease). This procedure may be delayed 3 months in patients with true stage I disease. At surgery, the undersurface of the tendon must be inspected for longitudinal split tears, and these must be repaired with nonabsorbable suture, burying the knots. The excursion of the tendon should be checked intraoperatively. Patients with stage I disease should be evaluated carefully for preoperative structural deformity to choose the appropriate surgical procedure and prevent failure of isolated tenosynovectomy.

Acute calcific tendinitis simulating tendon sheath infection

Tendon sheath infection has catastrophic consequences if not diagnosed. We present acute calcific tendinitis, a simulator of tendon sheath infection with a good prognosis in a 14 year old athletic tennis player.

Cavernous hemangioma behaving like peroneal tenosynovitis

Hemangioma of the tendon sheath is rarely reported. In this case report, a 22-year-old man, who had been seen for peroneal tenosynovitis before (although symptoms remained) was reevaluated. A cavernous hemangioma was located in the peroneal muscle and the tendon. Complete excision was performed.

Isolated tuberculous tenosynovitis of the flexor tendon of the fourth finger of the hand. Case report

A 21-year-old woman presented with a painful swelling of her palm which prevented her from fully extending her fourth finger. Magnetic resonance imaging showed synovial thickening around the flexor tendon and fluid in the tendon sheath. The mass was excised and histopathological examination showed tuberculosis. She had a six-month course of antituberculous treatment and was perfectly well three years later.

Avian reovirus infections

Avian reoviruses are ubiquitous among poultry flocks. Although infection is usually present without disease, reoviruses may occasionally be involved in several disease syndromes of which viral arthritis/tenosynovitis in chickens is the most important, particularly in broiler breeds. While reoviruses have been isolated from turkeys and several other species of birds with various conditions, the presence of the virus has been conclusively linked with disease in relatively few instances. In chickens in particular, avian reoviruses with a wide spectrum of pathogenic capability have been isolated and several antigenic types exist. Diagnosis is dependent on the detection of the virus in clinical samples, although the presence of the virus does not necessarily confirm that this is the cause of the disease, except where reoviruses are detected in affected joints. Serological tests are usually difficult to interpret in view of widespread and frequently harmless reovirus infection. The principal approach to control of viral arthritis/tenosynovitis is by vaccination using attenuated vaccines in young birds, followed by inactivated preparations for breeders intended to protect chicks by maternal antibodies. Many vaccines are based on the S1133 strain isolated in the United States of America, but these may not be effective against antigenic variants.

Magnetic resonance imaging, radiography, and scintigraphy of the finger joints: one year follow up of patients with early arthritis. The TIRA Group

OBJECTIVES

To evaluate synovial membrane hypertrophy, tenosynovitis, and erosion development of the 2nd to 5th metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints by magnetic resonance imaging in a group of patients with rheumatoid arthritis (RA) or suspected RA followed up for one year. Additionally, to compare the results with radiography, bone scintigraphy, and clinical findings.

PATIENTS AND METHODS

Fifty five patients were examined at baseline, of whom 34 were followed up for one year. Twenty one patients already fulfilled the American College of Rheumatology (ACR) criteria for RA at baseline, five fulfilled the criteria only after one year's follow up, whereas eight maintained the original diagnosis of early unclassified polyarthritis. The following MRI variables were assessed at baseline and one year: synovial membrane hypertrophy score, number of erosions, and tenosynovitis score.

RESULTS

MRI detected progression of erosions earlier and more often than did radiography of the same joints; at baseline the MRI to radiography ratio was 28:4. Erosions were exclusively found in patients with RA at baseline or fulfilling the ACR criteria at one year. At one year follow up, scores of MR synovial membrane hypertrophy, tenosynovitis, and scintigraphic tracer accumulation had not changed significantly from baseline; in contrast, swollen and tender joint counts had declined significantly (p<0.05).

CONCLUSIONS

MRI detected more erosions than radiography. MR synovial membrane hypertrophy and scintigraphy scores did not parallel the changes seen over time in clinically assessed swollen and tender joint counts. Although joint disease activity may be assessed as quiescent by conventional clinical methods, a more detailed evaluation by MRI may show that a pathological condition is still present within the synovium.

Mycobacterium kansaii flexor tenosynovitis presenting as carpal tunnel syndrome

We present a case in which Mycobacterium kansasii flexor tenosynovitis caused the development of carpal tunnel syndrome. The diagnosis was made from synovial tissue specimens taken at the time of operation.

[The macroscopic aspect of rotator cuff tears in traumatic and nontraumatic rupture cases]

The decision whether a rotator cuff tear has a traumatic or degenerative origin still causes some controversy. Especially in medical expert appraisals the etiology of the rotator cuff tear plays an important role referring to insurance services for the patient. The purpose of this paper is to compare the intraoperative pathomorphologic shape of the cuff tear in traumatic and degenerative cases. This study reports of 56 patients with rotator cuff tears which were divided in primarily acute, subacute traumatic and degenerative study groups referring to their history of present illness. We considered the location of the tear, the shape and the size. Furthermore the grade of retraction of the supraspinatus tendon, its quality and the shape of the long head of biceps were examined. The results showed that in general the shape of the tear gives only in some cases significant information whether the etiology is traumatic or not. The isolated rupture of the subscapularis muscle and the hematoma at the edge of the tendon is significant for the trauma. In comparison with the degenerative study group the tenosynovitis and the dislocation of the long head of biceps is in our study significant for traumatic tears.

Extensor pollicis longus tenosynovitis: a case report and review of the literature

A case of tenosynovitis of the extensor pollicis longus, or third dorsal compartment, is presented. This is an unusual condition that may be difficult to diagnose initially. A clinical test for extensor pollicis longus tenosynovitis is described. Operative treatment is recommended.

Painful heel: MR imaging findings

Heel pain is a common and frequently disabling clinical complaint that may be caused by a broad spectrum of osseous or soft-tissue disorders. These disorders are classified on the basis of anatomic origin and predominant location of heel pain to foster a better understanding of this complaint. The disorders include plantar fascial lesions (fasciitis, rupture, fibromatosis, xanthoma), tendinous lesions (tendinitis, tenosynovitis), osseous lesions (fractures, bone bruises, osteomyelitis, tumors), bursal lesions (retrocalcaneal bursitis, retroachilleal bursitis), tarsal tunnel syndrome, and heel plantar fat pad abnormalities. With its superior soft-tissue contrast resolution and multiplanar capability, magnetic resonance (MR) imaging can help determine the cause of heel pain and help assess the extent and severity of the disease in ambiguous or clinically equivocal cases. Careful analysis of MR imaging findings and correlation of these findings with patient history and findings at physical examination can suggest a specific diagnosis in most cases. The majority of patients with heel pain can be successfully treated conservatively, but in cases requiring surgery (eg, plantar fascia rupture in competitive athletes, deeply infiltrating plantar fibromatosis, masses causing tarsal tunnel syndrome), MR imaging is especially useful in planning surgical treatment by showing the exact location and extent of the lesion.

['Trigger thumb' in 38 children: good short-term and long-term results from surgery]

OBJECTIVE

To determine the direct and long-term effectivity of incision of the pulley in a trigger thumb (tendovaginitis stenosans).

DESIGN

Retrospective study with follow-up.

METHODS

In the period 1984-1995, 38 children (24 boys and 14 girls) were diagnosed and operated on 45 trigger thumbs in the Onze Lieve Vrouwe Gasthuis (Amsterdam) and Medisch Centrum Alkmaar, the Netherlands. Data were obtained from notes, operation reports and review in follow-up, at least 2 years after the operation.

RESULTS

The mean age of the children at the moment of surgery was 3 years and 2 months (range: 11 months-10.33 years). 39 out of 45 thumbs were reviewed. Four thumbs had limited postoperative function. Two of these had a revision operation. There was 1 thumb with a postoperative superficial infection. At follow-up all thumbs had maximal function. The nodule in the tendon, which was palpable in 43 out of 45 thumbs preoperatively, had (almost) disappeared in all 39 thumbs at follow-up. There was a family history of trigger thumb in 33% of the 33 patients with follow up. 18% had bilateral involvement of the thumbs. The 6 digits not included in follow-up had a normal function according to the last notes.

CONCLUSION

The results of surgery in the short term are good, in the long term excellent. Few complications occur. Based on the findings, it seems advisable to operate on children with a trigger thumb if there is no spontaneous recovery within half a year. Trigger thumb is the result of a congenital tight pulley.

Evaluation and management of chronic work-related musculoskeletal disorders of the distal upper extremity

This clinical review will describe the epidemiology, clinical presentation, and management of the following work-related musculoskeletal disorders (WMSDs) of the distal upper extremity: deQuervain's disease, extensor and flexor forearm tendinitis/tendinosis, lateral and medial epicondylitis, cubital tunnel syndrome, and hand-arm vibration syndrome (HAVS). These conditions were selected for review either because they were among the most common WMSDs among patients attending the New York State Occupational Health Clinics (NYSOHC) network, or because there is strong evidence for work-relatedness in the clinical literature. Work-related carpal tunnel syndrome is discussed in an accompanying paper. In an attempt to provide evidence-based treatment recommendations, literature searches on the treatment of each condition were conducted via Medline for the years 1985-1999. There was a dearth of studies evaluating the efficacy of specific clinical treatments and ergonomic interventions for WMSDs. Therefore, many of the treatment recommendations presented here are based on a consensus of experienced public health-oriented occupational medicine physicians from the NYSOHC network after review of the pertinent literature. A summary table of the clinical features of the disorders is presented as a reference resource.

[The role of magnetic resonance in the diagnosis of the os trigonum syndrome]

PURPOSE

We investigated the yield of Magnetic Resonance Imaging (MRI) in hindfoot conditions, particularly the os trigonum syndrome, which are very difficult to diagnose clinically.

MATERIAL AND METHODS

We examined 7 consecutive patients complaining of hindfoot pain for more than 4 months (male:female = 1:6; age range 16-22 years, average 18.6). Three patients practiced competitive sports and 4 ballet. We performed conventional radiography (orthogonal projections) and then MRI with a 0.5 T superconductive unit with surface coils; MR images were acquired with T1-weighted spin-echo (SE), T2-weighted gradient-echo (GRE), and fast inversion recovery (FIR) fat-suppressed sequences with 4 mm thickness and 0 mm gap.

RESULTS

In 2 cases the os trigonum had irregular margins with subchondral sclerosis and widened synchondrosis. In 3 patients we found flexor hallucis longus tenosynovitis, likely caused by tendon compression and displacement within its sheath; there were neither os trigonum marrow edema nor synchondrosis widening. One patient had os trigonum hypertrophy, mild synchondrosis widening and marrow edema, in the os trigonum and the posterior aspect of talus. One patient had the os trigonum, but no signs referable to the os trigonum syndrome.

CONCLUSIONS

In the posterior impingement syndrome, our objective is to show inflammatory changes in the posterior capsule of the ankle joint, adjacent ligaments, tendons and chondrosynovial surface. In these cases, the yield of conventional radiography and CT is rather poor, while MRI provides important information on soft tissues involvement, synovial reaction, chondral and subchondral bone injuries and the association of flexor hallucis longus synovitis, if present. MRI also yields detailed information for correct therapeutic approach. In conclusion, for the (differential) diagnosis of hindfoot pain in clinically suspected os trigonum syndrome, MRI appears to be the technique of choice, after conventional radiography, thanks to its noninvasiveness, multiplanarity, and high spatial and contrast resolution.

Intersection syndrome: a case report and review of the literature

Intersection syndrome is a condition that should be differentiated from DeQuervain's stenosing tenosynovitis, as there are many subtle differences in treatment and prognosis. We present a case of intersection syndrome, describing its characteristic clinical and anatomic features, and highlighting differences in the areas of diagnosis and treatment relative to the better known DeQuervain's tenosynovitis.

Imaging of the rotator cuff and biceps tendon

Several different imaging techniques are available for evaluating the rotator cuff and biceps tendon. The common disorders of impingement, rotator cuff tears and biceps tendonitis are discussed along with the role which the various imaging modalities can play in establishing their diagnosis. Plain radiographs can be helpful particularly with a history of trauma but give limited information on the soft tissues. Ultrasound is a useful and inexpensive means of assessing the rotator cuff and biceps tendon but has a number of limitations and varying reports on its accuracy. Computed tomography (CT) is most helpful in the evaluation of shoulder trauma but gives limited information on the soft tissues. Magnetic resonance imaging (MRI) is an accurate imaging modality for evaluating the rotator cuff and biceps tendon, allowing visualisation of the soft tissues and the adjacent bony structures.

Non-tuberculous mycobacterial tenosynovitis: a review

The clinical characteristics, outcome and treatment of non-tuberculous mycobacterial tenosynovitis are reviewed. From lesions localized in the hand, 10 different species of non-tuberculous mycobacteria have been reported. The most common are Mycobacterium marinum and Mycobacterium kansasii. Other less frequent organisms are Mycobacterium avium complex, Mycobacterium szulgai, Mycobacterium terrae, Mycobacterium fortuitum, Mycobacterium chelonae, Mycobacterium abscessus, Mycobacterium malmoense and Mycobacterium xenopi. The infections appear to be the result of previous trauma, surgical procedure, corticosteroid injection or non-apparent inoculation (water contamination). Immunosuppression is sometimes associated with the infections and can be considered as a risk factor. Surgical debridement and appropriate mycobacterial cultures are critical to enable diagnosis and appropriate management. Specimens should be inoculated on a range of media and incubated at a range of temperatures in order to isolate mycobacteria with different growth characteristics (with prolonged incubation). The optimal treatment of these infections is discussed.

A narrative review on classification of pain conditions of the upper extremities

Local and regional musculoskeletal discomfort and pain in the shoulder girdle or upper extremities are often reported, especially in the working population. In this review we describe the most important problems and factors when classifying musculotendinous pain in the upper extremities and shoulders. This includes an analysis of how four common diagnoses (wrist tenosynovitis, lateral epicondylitis, rotator-cuff tendinitis, myofascial pain syndrome) fulfil basic criteria of validity. It is evident that there are some serious problems regarding the validity of the current classification of the conditions. Clinical criteria are often poorly defined and the reliability insufficiently tested. The relationship to objective pathoanatomic or physiological findings seems inconsistent. Although magnetic resonance and ultrasonographic imaging are promising, they are still only preliminary methods for evaluation of tendon and connective tissue structures. The prognosis with and without treatment also seems heterogeneous and can vary between studies. A generally accepted terminology is lacking in the pathogenetically complex regional muscle pain conditions.

Distal extremity swelling with pitting edema in psoriatic arthritis: evidence of 2 pathological mechanisms

Distal extremity swelling with pitting edema due to altered lymphatic drainage has been reported in some patients with psoriatic arthritis (PsA). The edema usually affected the upper limbs in an asymmetric pattern and was resistant to therapy. We describe 2 additional cases. The distal swelling and pitting edema responded promptly and completely to corticosteroids in the first patient but persisted in the second. Lymphoscintigraphy and magnetic resonance imaging (MRI) revealed a predominant tenosynovitis in the hand without lymphedema in the first patient, and impaired lymphatic drainage without tenosynovial sheath involvement in the second. We conclude that 2 different mechanisms, characterized by a different response to therapy, may be associated with the same clinical picture of distal swelling with pitting edema in patients with psoriatic arthritis. Lymphoscintigraphy and MRI are useful in defining the structures involved and in predicting the prognosis.

The use of magnetic resonance imaging in posterior tibial tendon dysfunction

The role of magnetic resonance imaging in the evaluation of the patient with posterior tibial tendon dysfunction is discussed. Considerations for the proper positioning of the patient and optimal technique to obtain appropriate images of the posterior tibial tendon and associated joint abnormalities are highlighted. Cases are presented to show the effectiveness of magnetic resonance imaging in different clinical situations. The treatment algorithm for posterior tibial tendon dysfunction should include magnetic resonance imaging as a diagnostic tool when appropriate.

Os trigonum syndrome with flexor hallucis longus tenosynovitis in a professional football referee

The presentation of posterior ankle pain in any patient poses a diagnostic dilemma. The os trigonum syndrome and flexor hallucis longus stenosing tenosynovitis have been reported to occur in professional and amateur ballet dancers. It is important to consider these diagnoses in a patient who is not a dancer, as is shown in the case presented here. The patient in this case is a professional referee who injured his ankle while working on artificial turf. The treatment for os trigonum syndrome and flexor hallucis longus tenosynovitis is initially conservative, but in refractory cases, surgical removal of the os and release of the flexor hallucis longus tendon can be successfully performed. This is the first reported case of os trigonum syndrome and flexor hallucis longus tenosynovitis presenting simultaneously in a patient who is not a dancer.

Regional musculoskeletal pain. The elbow, forearm, wrist and hand

Two main groups of soft-tissue disorders are identified: specific soft tissue syndromes and a non-specific disorder as yet not fully characterized. Specific soft tissue syndromes occur in joint, muscle or nerve and are associated with characteristic symptoms and physical signs. These include epicondylitis at the elbow, tendon disorders at the wrist and nerve entrapments such as carpal tunnel syndrome. The non-specific soft tissue syndrome is primarily described by symptoms of pain but may include muscular symptoms (such as weakness and cramp) or nerve symptoms (such as numbness, pins and needles, and burning). Agreed, validated diagnostic criteria for use in surveillance are urgently required. Biological markers are still sought; both muscle and nerve seem promising for future studies. The multifactorial aetiology of these disorders will be discussed, and guidelines to management will embrace the principles of this model. Treatments aimed at the pain in isolation are most often studied. Psychosocial and environmental influences on the presentation and persistence of pain need further evaluation.

Hand infections in the trauma patient

Infections are a frequent, unfortunate complication seen in orthopedic trauma patients. The specific anatomy of the upper extremity makes it an easy target for opportunistic organisms, especially after an acute traumatic event. In addition, pathogenic factors and host factors can contribute to the severity of the infection. Meticulous wound management, identification of the offending organism(s), and tailoring of care to the special needs of the very sick trauma patient limit complications.

Remitting seronegative symmetrical synovitis with pitting oedema (RS3PE) syndrome: a prospective follow up and magnetic resonance imaging study

OBJECTIVE

To determine the clinical characteristics of patients with "pure" remitting seronegative symmetrical synovitis with pitting oedema (RS3PE) syndrome, and to investigate its relation with polymyalgia rheumatica (PMR). Magnetic resonance imaging (MRI) was used to describe the anatomical structures affected by inflammation in pure RS3PE syndrome.

METHODS

A prospective follow up study of 23 consecutive patients with pure RS3PE syndrome and 177 consecutive patients with PMR diagnosed over a five year period in two Italian secondary referral centres of rheumatology. Hands or feet MRI, or both, was performed at diagnosis in 7 of 23 patients.

RESULTS

At inspection evidence of hand and/or foot tenosynovitis was present in all the 23 patients with pure RS3PE syndrome. Twenty one (12%) patients with PMR associated distal extremity swelling with pitting oedema. No significant differences in the sex, age at onset of disease, acute phase reactant values at diagnosis, frequency of peripheral synovitis and carpal tunnel syndrome and frequency of HLA-B7 antigen were present between patients with pure RS3PE and PMR. In both conditions no patient under 50 was observed, the disease frequency increased significantly with age and the highest frequency was present in the age group 70-79 years. Clinical symptoms for both conditions responded promptly to corticosteroids and no patient developed rheumatoid arthritis during the follow up. However, the patients with pure RS3PE syndrome were characterised by shorter duration of treatment, lower cumulative corticosteroid dose and lower frequency of systemic signs/symptoms and relapse/recurrence. Hands and feet MRI showed evidence of tenosynovitis in five patients and joint synovitis in three patients.

CONCLUSION

The similarities of demographic, clinical, and MRI findings between RS3PE syndrome and PMR and the concurrence of the two syndromes suggest that these conditions may be part of the same disease and that the diagnostic labels of PMR and RS3PE syndrome may not indicate a real difference. The presence of distal oedema seems to indicate a better prognosis.

Videotapes in evaluating work-related upper extremity symptoms

Thirteen patients with upper extremity symptoms that were claimed to have occurred in the course of employment were evaluated to determine the role of videotapes in their evaluation and management. Videotapes were of two types: work demonstration by patient or coworker (8 tapes) and surveillance tapes obtained by a private investigator (5 tapes). Four of eight work station videotapes demonstrated significant repetitive motion that could have contributed to their symptoms. Four of eight work station videotapes demonstrated that the tasks were neither forceful nor repetitive in nature. Return to work recommendations were made based on both clinical grounds and job site information provided on tape. After viewing five surveillance videotapes, two fraudulent claims were settled soon after medical opinions were rendered. Two patients were declared able to return to work; one returned to work and the other was dismissed. The videotape of patient No. 13 was not crucial for the decision and he was authorized to have surgery. The opinions formed concerning the causality of alleged claims of injury were often altered by viewing the content of the videotapes. Videotapes are a valuable tool and useful adjunct in the overall management of the workers with upper extremity symptoms.

Imaging of the painful shoulder

A variety of imaging techniques are available for evaluating shoulder pathology. The common disorders of impingement, rotator cuff tears, biceps tenosynovitis and instability are discussed along with the role of various imaging modalities in establishing their diagnosis. Plain radiographs can provide useful information particularly with a history of trauma but give limited information on the soft tissue structures around the shoulder. Ultrasound is a useful and inexpensive means of assessing the biceps tendon and rotator cuff but has a number of limitations and varying reports on its accuracy. Computed tomography (CT) is most helpful in the evaluation of shoulder trauma but gives limited information on the soft tissues. When performed with intra-articular contrast, CT can be used to evaluate shoulder instability particularly in cases where magnetic resonance imaging (MRI) is not available or contraindicated. MRI with or without intra-articular contrast is the most accurate imaging modality for evaluating shoulder pathology allowing visualization of the soft tissues that are often the source of pain.

Tenosynovitis associated with longitudinal tears of the digital flexor tendons in horses: a report of 20 cases

The paper describes a series of cases with longitudinal tears in the superficial or deep digital flexor tendons within the digital flexor tendon sheath. This appears to be a previously unreported condition. Twenty cases are described, one horse was affected bilaterally. Nineteen defects involved the deep digital flexor tendon and in 2 horses the manica flexoria of the superficial digital flexor tendon was torn. All affected horses were lame and there was marked distension of the digital flexor tendon sheaths. Ultrasonography revealed nonspecific signs of chronic tenosynovitis but not the cause. Diagnosis was established by tenoscopy in 9 cases and by open surgical exploration in the remainder. In 7 limbs, the deep digital flexor tendon lesions were treated by removal of the torn fibrils under tenoscopic control. In the remaining cases they were removed and the defects were repaired with absorbable suture material. Wound closure in all open cases included repair of the palmar/plantar annular ligament. Eleven horses became sound and returned to work, 3 improved but were lame on returning to work and 2 horses did not improve following treatment. At the time of reporting, 4 horses are sound and in controlled ascending exercise regimes. It is concluded that longitudinal tears of the digital flexor tendons should be considered in the differential diagnosis of tenosynovitis of the digital flexor tendon sheath. The results presented suggest that accurate diagnosis and specific treatment justify surgical investigation.

Isolated tenosynovitis associated with psoriasis triggered by physical injury

A 60-year-old man who had been suffering from psoriasis for 20 years developed finger dactylitis and inflammatory swelling with pitting edema over the dorsum of the hand one week after a contusive trauma to the left hand. These were not followed by any other clinical manifestations of PsA.

Mycobacterium malmoense infection. An unusual cause of wrist swelling

We report a case of non-tuberculous tenosynovitis of the wrist caused by Mycobacterium malmoense. The patient presented with a ganglion-like swelling on the flexor aspect of the wrist. The diagnosis was confirmed by fine needle aspiration biopsy. A satisfactory resolution was obtained by antibiotic therapy alone, indicating that radical synovectomy may not be necessary in all cases of M. malmoense infection.

[Carpal tunnel syndrome in childhood. A case of early onset]

INTRODUCTION

The carpal tunnel syndrome (CTS) is the commonest neuropathy due to compression to be seen in adults. There are very few cases in the literature referring to patients of paediatric age, particularly those under ten years old. Most of these young patients had a metabolic disorder (mucopolysaccharidosis (MPS) or mucolipidosis (ML). In fact, as many as 90% of the MPS had CTS, sometimes subclinically. This syndrome is caused by compression of the median nerve at the level of the carpal tunnel, to which multiple factors may contribute, both local and systemic, as reviewed in this paper. The clinical findings differ from those in adults, but the appearance of suggestive symptoms and signs should make one suspect the condition and request an electromyographic study (EMG) which would be diagnostic.

CLINICAL CASE

We describe the case of a five year old girl, with a clinical history suggesting the presence of a carpal tunnel syndrome for 12 months and characterized by paraesthesia and limitation of flexon-extension movements of the fingers of the affected hand, with pain on movement. The symptoms appeared on waking in the morning, gradually improved as the day advanced and became bilateral over a period of six months. The diagnosis was confirmed by EMG and MR helped to clarify the aetiology.

CONCLUSION

The interesting aspect of this article is the youth of the patient, the absence of known etiological factors and the presence of tenosynovitis detected on MR as has been described in some idiopathic/familial forms.

Trigger wrist and flexor tenosynovitis

We report a case of a profundus tendon sheath fibroma which initially presented as triggering on wrist movements but rapidly caused a flexor tenosynovitis limiting both finger and wrist movements. Surgical excision was curative.

Kluyvera cryocrescens finger infection: case report and review of eighteen Kluyvera infections in human beings

We report a case of soft tissue infection with Kluyvera cryocrescens and a critical review of Kluyvera infections. A 31-year-old diabetic man used a new chemical for stripping the floor with his bare hands. Two days later he developed a blister on a finger which progressed to tenosynovitis in spite of intravenous nafcillin therapy. After 11 days culture and sensitivity results dictated treatment with intravenous ticarcillin/clavulanic acid. The wound was debrided twice, and later a skin flap was done. Wound cultures became sterile after 7 days of treatment with ticarcillin/clavulanic acid, and he recovered. This case represents the fourth clinical infection with K. cryocrescens and the eighteenth of Kluyvera to be reported. Four others were K. ascorbata, and the remaining ten Kluyvera infections in humans were not identified beyond genus. Our case and review of the 17 previous cases emphasize that while Kluyvera rarely cause disease, these opportunistic Gram-negative bacilli may be virulent in a variety of sites under as yet poorly defined host conditions. Sites of infection varied, but the brain and meninges were not among them. Two patients had diabetes mellitus, none had AIDS, and four died. Once shown clinically to be the cause of an infection, Kluyvera deserve aggressive treatment which acknowledges their ampicillin resistance.

Pyogenic flexor tenosynovitis

The clinical features of an infected finger flexor tendon sheath have changed dramatically since the pre-antibiotic time of Kanavel. The hand surgeon is encountering increasing numbers of gram-negative and mixed organism infections, especially in immunocompromised patients or those with comorbidities such as diabetes mellitus. The prognosis is directly related to the early recognition of the disease process and prompt surgical drainage and sheath irrigation, in combination with an appropriate antibiotic regimen. Despite appropriate management, some patients still develop significant complications. This possibility must be particularly recognized in diabetic and immunocompromised patient populations.

Magnetic resonance imaging of the peroneal tendons

Injuries of the peroneal tendons include tendinosis, tenosynovitis, tears, and dislocation. These injuries are being detected with greater frequency since the advent of MRI. After a review of the normal MRI anatomy of the peroneal tendons, this article will focus on the MR features of peroneal tendon disorders in the foot and ankle.

Limited surgical treatment of de Quervain's disease: decompression of only the extensor pollicis brevis subcompartment

A septum between the abductor pollicis longus tendon and the extensor pollicis brevis (EPB) tendon in the first extensor compartment is frequently encountered during surgical treatment of de Quervain's disease. It was hypothesized that de Quervain's disease was secondary to EPB entrapment and the decision was made to decompress only the EPB subcompartment. Twenty-two patients were treated with this method. Sixteen patients had a septum in the first extensor compartment and 6 patients had a single canal. After surgery, all patients had complete relief of pain and tenderness over the first extensor compartment. The results of Finkelstein's test were negative in all cases. We conclude that de Quervain's disease is secondary to EPB entrapment. In those cases with a septum, it is sufficient to decompress only the EPB subcompartment.

Miliary tuberculosis presenting as tenosynovitis in a case of rheumatoid arthritis

A 77-year-old woman with a seropositive nodular rheumatoid arthritis and vasculitis, who was treated with high doses of corticosteroids and intravenous cyclophosphamide, developed miliary tuberculosis that was heralded by a tenosynovitis in her right wrist. A 1-year course of anti-tuberculous therapy resulted in complete resolution of the tenosynovitis and disseminated infection.