R. Brooke Jeffrey, Jr.

, MD #{149}
Faye C. Laing, MD William P. Schechter, #{149} MD
#{149}
Robert E. Markison, MD Ronald M. Barton, #{149} MD

Acute Suppurative Tenosynovitis

ofthe Hand: Diagnosis with US’

The sonographic findings in seven suppunative

CUTE tenosynovitis Mountain View, Calif.) and either a water
patients with surgically proved has been called the most disas- bath or a stand-off gel mattress (Reston
trous of all hand infections (1), and [3M Company], Minneapolis). Longitudi-
acute tenosynovitis of the hand
nal and transverse images were obtained
(bacterial in six cases, of presumed prompt surgical drainage is essential
of the affected tendons at rest and when
viral origin in one) were reviewed. to preserve tendon function (1-4). In
possible during passive motion to facili-
In the six patients with bacterial te- the past, clinicians have relied entire- tate visualization of the tendon. Scans
nosynovitis the affected flexor ten- ly on clinical symptoms and physical were compared with scans of the contra-
don was larger than that of the con- examination findings to establish the lateral normal tendon.
tralateral normal digit. In five diagnosis. This report summarizes
patients hypoechoic areas were the sonographic features in six surgi-
RESULTS
identified surrounding the flexor cally proved cases of acute bacterial
tendon that proved to be pus at sur- tenosynovitis and one case of pre- In all six patients with bacterial
gery. Sonography failed to depict a sumed viral origin. Although these tenosynovitis the involved flexor
small amount of pus in the tendon results are preliminary, the ability to tendon was larger than the contralat-
sheath in one patient The affected image the tendon and tendon sheath eral normal tendon (Figs. 1, 2). On
tendon of the single patient with directly by ultrasound (US) appears transverse sonograms the diameter of
tenosynovitis thought to be of viral to be useful in the early diagnosis of the involved tendon was 25% greater
origin was normal in size, but a fo- suppurative tenosynovitis. than the diameter of the normal con-
cal tendon sheath fluid collection tralateral tendon. In the one patient
was detected that proved to be ster- with presumed viral tenosynovitis
ile at surgery. Sonography appears MATERIALS AND METHODS the involved tendon was of normal
to be a useful imaging technique in Preoperative sonograms were obtained size compared with the normal con-
the early diagnosis of acute sup- in seven male patients aged 5-34 years tralatenal tendon. In five of six pa-
purative tenosynovitis of the hand. with clinically suspected acute suppura- tients with bacterial tenosynovitis,
tive tenosynovitis. Six patients had sus- hypoechoic areas adjacent to and sun-
Index terms: Hand, injuries Hand,
#{149} US stud- tamed a recent puncture wound to the rounding the tendon suggested ten-
ies, 43.12981 Tenosynovitis,
#{149} 43.252 palmar surface of the hand with pain and don sheath fluid collections (Fig. 2).
limitation of motion of the involved dig- The fluid was confirmed to be pus at
Radiology 1987; 162:741-742 it. In one patient progressive swelling
surgery. In one patient US failed to
and limitation of motion of the right in-
disclose a small amount of tendon
dex finger developed during hospitaliza-
sheath pus that was found at surgery
tion for viral penicarditis.
Preoperative real-time US was per- (Fig. 1). The tendon of the patient
formed in each patient using a 5-MHz with presumed viral tenosynovitis
linear-array real-time scanner (Acuson, appeared normal, but a focal fluid

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a. b.
I From the Departments of Radiology (R.B.J.,
Figure 1. Tendon enlargement secondary to acute bacterial tenosynovitis. (a) Sagittal view
F.C.L.), and Surgery (W.P.S., REM., R.M.B.),
San Francisco General Hospital, San Francisco, of left index finger at level of middle phalanx (arrows) demonstrates increased size of flexor
CA 941 10. Received August 22, 1986; accepted tendon (between cursors). (The location of the distal phalanx is reversed from that in Fig. 2.)
and revision requested September 29; revision Although no tendon sheath fluid was detected sonographically, a small amount of pus was
received November 1 1 . Address reprint re- drained from tendon sheath at surgery. D distal digit, P palmar surface. (b) Sagittal view
quests to R.B.J. of contralateral normal right flexor tendon (between cursors) at level of middle phalanx. Ar-
e RSNA, 1987 rows indicate middle phalanx. D distal digit, P palmar surface.

741
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ii .:
4- .

Figure 3. Acute tenosynovitis, presumed to

Figure 2. Acute bacterial tenosynovitis after puncture wound to the hand. (a) Sagittal scan
be of viral origin. Transverse scan at level of
of flexor tendon of right second digit at level of middle phalanx. Note diffuse enlargement the distal third of the metacarpal heads and
of the flexor tendon (T). Cursors are on outer margin of hypoechoic tendon sheath. Open an- the distal palm demonstrates a focal tendon
row denotes the middle phalanx. P = palmar surface, D distal digit. (b) Transverse scan of sheath fluid collection (open arrow) adja-
second, third, and fourth digits at the level of the proximal phalanx demonstrates a hypo-
cent to the third flexor tendon (T). Note that
echoic area (arrows) surrounding an enlarged, echogenic flexor tendon (7). The appearance third flexor tendon (3) is similar in size to
is compatible with tendon sheath fluid, which was found to be pus at surgery.
the fourth flexor tendon (arrow, 4).

collection was detected adjacent to uming of the lumbnical muscles or tive motion of the digit; and clinical
the flexor tendon (Fig. 3) and proved other technical factors such as beam evidence of fever, leukocytosis, and!
to be sterile on culture. refraction (5). on lymphangitis (2, 3). As noted by
All seven patients underwent sun- A 25% on greaten increase in diame- Kanavel (4), the involved finger is
gical exploration within 48 hours of ten of the affected tendon compared characteristically held in a semi-
US that confirmed tenosynovitis. At with the contralatenal normal tendon flexed position. In this clinical set-
surgery the tendon sheath was in- was a striking feature in all six pa- ting the sonognaphic demonstration
cised and drained, and an irrigating tients with bacterial tenosynovitis in of enlargement of the tendon and an
catheter was placed for closed irniga- this series. To date we have not stud- adjacent tendon sheath fluid collec-
tion of the tendon sheath. ied a large population of healthy sub- tion confirms the clinical diagnosis
jects to see if there are slight vania- of suppunative tenosynovitis. The US
tions in tendon size between night findings may obviate further expec-
DISCUSSION
and left hands, or how tendon size tant therapy with antibiotics and
The digital flexor tendons glide relates to “handedness.” Comparison prompt earlier surgical interven-
through fibroosseous sheaths that ex- of thickness between extension and tion. U
tend from the distal palm to the dis- partial flexion must also be consid-
tal interphalangeal joints. In the ered. References
presence of suppurative tenosynovi- Hypoechoic areas surrounding the 1. Carter SJ, Mersheemer WL. Infections of
tis, pus may develop under pressure flexor tendon correlated well with the hand. Orthop Clin North Am 1970;
1:455-466.
within the closed space of the tendon pus found within the tendon sheath
2. Wilson DH. Tenosynovitis, tendovaginitis
sheath and may disrupt arterial and at surgery. This observation is similar and trigger finger. Physiotherapy 1983;
venous flow, resulting in tendon to the sonographic abnormalities de- 69:350-352.
ischemia (4). If avasculan necrosis oc- scnibed by Blei et al. in regard to 3. Neviaser RJ. Closed tendon sheath irriga-

tenosynovitis of the Achilles tendon tion for pyogenic flexor tenosynovitis.

curs, dense adhesions between the
Hand Surg 1978; 3:462-466.
tendon and the flexor sheath will ul- (6). Diffuse thickening of the exten-
4. Kanavel AB. Infections of the hand. Phila-
timately develop, resulting in a pain- son pollicis brevis and abductor polli- delphia: Lea & Febiger, 1943; 24 1-242.
ful, functionless digit (4). cis longus tendons at the wrist has 5. Fornage BD, Rifkin MD. Ultrasound ex-
been observed sonographically in de amination of the hand. Radiology 1986;
As noted by Fornage and Rifkin
160:853.
(5), the normal flexor tendon appears Quenvain stenosing tenosynovitis (7).
6. Blei CL, Nirschl RP, Grant EG. Achilles
sonographically as an echogenic However, the sonographic features tendon: US diagnosis of pathologic condi-
structure. This appearance is often of suppurative tenosynovitis in the tions. Radiology 1986; 159:765-767.
best seen in transverse views, since hand and the importance of tendon 7. Fornage BD, Schernberg FZ, Rifkin MD.
Ultrasound examination of the hand. Radi-
in the sagittal view the region of the sheath fluid have not been stressed.
ology 1985; 155:785-788.
normal tendon may appear slightly The clinical findings suggesting
hypoechoic. Fonnage and Rifkin have suppurative tenosynovitis include a
attributed this to either partial vol- puncture wound that may have en-
tened the tendon sheath; a symmetni-
cally swollen, tender, and inflamed
finger; pain on either passive or ac-

742 . Radiology March 1987