Tuberculous Tenosynovitis of the Wrist and the Hand: The 3 Anatomo- Clinical Forms Described by Kanavel (About 4 Cases)

Abstract

Introduction: Tuberculous tenosynovitis localization is rare. This unusual presentation, often misunderstood, results in frequent misdiagnosis. We report 4 cases of patients which represent the 3 anatomo-clinical forms described by Kanavel. The knowledge of its different manifestations will make it possible to recognize and to suspect the tuberculous origin.

Case report: This was a retrospective study from January 2006 to May 2017 which involved all patients received and treated with tuberculous tenosynovitis. Of the 4 case studies presented here, there were 3 men and 1 woman, aged, respectively, 23, 30, 40, and 30 years of age. They were all immunocompetent. The onset was, respectively, about 12, 6, 4, and 8 months. The localization was on the wrist for 3 cases (2 on the right and 1 on the left) and one on the palmar face of the second ray on the right hand. Signs of median nerve compression were found in 2 cases. Surgery was extensive, with a complete debridement in 3 patients. For the last one, a simple recess was made associated with a bacteriological sampling. Biopsy was performed for all patients. In the anatomo-clinical study, we observed 1 case of serofibrinous synovitis, 2 cases of rice-like synovitis, and 1 case of caseous synovitis. A rupture of the tendon ofthe flexor carpi radialis was observed in 1 case. All cases were confirmed histologically with the presence of granuloma gigantocellular with caseous necrosis. We have recorded 1 case ofbacteriological positivity in 3 cases requested. Patients had antituberculous chemotherapy after surgery for, respectively, 6, 8, 6, and 8 months. The progression was favorable with a regression of the signs of nerve compression. Revisited at, respectively, 4, 3, 5 years, and 34 months, we did not record any recurrence. The mobility of the wrist was complete and partial for the finger.

Conclusion: Tenosynovitis tuberculous treatment is mostly medical. Early diagnosis enables the treatment to be started as soon as possible to avoid extensive surgery. For this reason, it is currently essential to use high sensitivity diagnostic methods of such as the polymerase chain reaction method and the Genexpert in any suspicion of the disease.

Keywords: Genexpert; Tenosynovitis; caseous; hand; polymerase chain reaction; tuberculous; wrist.

Figure 2

The classic appearance of a bissac or hourglass in clinical view in patient 2. This is the clinical aspect of the right wrist of patient 2 that shows swelling on the palmar face giving the classic appearance of a bissac or hourglass. This aspect is due to the fact that the sheath passes under an aponeurotic formation.

Figure 1

Synovial sheath of the extensors tendons with the presence of caseous lumps in patient1. This figure shows a synovial mass, which after the excision discovers the extensor tendons at the dorsal side ofthe left wrist. We see many caseous lumps. This aspect corresponds to the caseous form of synovitis.

Figure 3

Large synovial mass passing through the carpal tunnel in patient 2. This is an intra- operative view that shows a mass at the volar side of the wrist containing all the flexor tendons ofthe fingers and the median nerve including in patient 2. Some riziform grains were found after release of carpal canal giving the granulomatous form of synovitis or rice-like synovitis.

Figure 4

Macroscopic aspect of the synovium show an exudative form of synovitis in patient 3. This mass is localized on the palmar face of the right hand and extends to the second ray. The Macroscopic aspect ofthe synovium shows an exudative form ofsynovitis.

Figure 5

Minimal approach with many riziform grains giving the granulomatous form of synovitis in patient 4. This is an intraoperative view that shows a mass at the anterior side ofthe wrist. A recess of the swelling zone has allowed to the outcome of many riziform grains giving the granulomatous form of synovitis or rice-like synovitis.