J Hand Microsurg 2021; 13(03): 202-204
DOI: 10.1055/s-0040-1714928
Letter to the Editor

Tendon Rupture in a Patient with Tuberculosis of the Hand Misdiagnosed as a Recurrent Dorsal Wrist Ganglion

1   Division of Plastic Surgery, Department of Surgery, King Saud University, Riyadh, Saudi Arabia
› Author Affiliations

Tuberculosis tenosynovitis of the hand usually involves the flexor tendons. In contrast, extensor tuberculosis tenosynovitis is much less common than flexor tendon disease.[1] [2] Computed tomography scans and magnetic resonance imaging (MRI) may allow the evaluation of the three pathological stages of the tenosynovial disease: the hygromatous (increased synovial fluid and mild synovial proliferation), the serofibrinous (moderate synovial thickening with rice bodies), and the fungoid (marked synovial thickening and necrotizing granulomatous inflammation) stages.[3]

A 40-year-old, otherwise healthy, female was referred to the hand clinic with the diagnosis of a recurrent dorsal wrist ganglion. Six months prior to the presentation, she underwent surgery at her local hospital. According to the previous medical report, the clinical diagnosis was a dorsal wrist ganglion related to the extensor tendons. Excision was done, but no specimen was sent for histopathology. One month later, she started developing a slowly growing mass more proximal to the surgical scar. The mass started to ulcerate and the patient was referred to our clinic for excision of the “recurrent” wrist ganglion ([Fig. 1]). There was no past history of pulmonary tuberculosis or family history of tuberculosis. There was no history of constitutional symptoms. Examination showed the mass and good extensor function to all digits with full range motion. The extensor carpi ulnaris could not be palpated. MRI was highly suggestive of tuberculosis and showed marked synovial hypertrophy and thickening which was more marked on the ulnar side ([Fig. 1]). The extensor carpi ulnaris was not in-continuity indicating rupture, but all other extensor tendons appeared in-continuity. Large amount of fluid and rice bodies were also noted on the radial side within the synovial mass ([Fig. 1]). Preoperative chest X-ray was unremarkable. Tuberculin test was positive (15 mm). Routine blood tests showed no abnormalities but the erythrocyte sedimentation rate was elevated (60 mm/h). Our clinical diagnosis was tuberculous extensor tenosynovitis which was in the serofibrinous stage on the radial side and in the fungoid stage on the ulnar side. A longitudinal incision was made across the wrist. The MRI findings were confirmed intraoperatively. There was marked thickening of the synovium ([Fig. 2]), which was infiltrating the extensor tendons of the ring and little fingers. Rice bodies were also noted ([Fig. 2]). The extensor carpi ulnaris was ruptured and retracted proximally. About 50% of the substance of the extensor tendon of the ring finger (over a 1-cm distance) was eaten up by the inflammatory process ([Fig. 2]). Furthermore, the extensor digitorum of the little finger could not be salvaged and was resected over a 3-cm distance to complete the synovectomy ([Fig. 2]). However, the extensor digiti minimi was intact. No tendon transfer or tendon grafting was done, and the wound was closed with a suction drain. A wrist splint was applied, leaving all digits free for immediate postoperative physiotherapy. Tissue cultures isolated Mycobacterium tuberculosis. Histopathology showed caseating granulomas with areas of necrotizing granulomatous inflammation. One month after the surgery, rupture of the extensor tendon of the ring finger was noted. The patient completed a 9-month course of antituberculous medications (isoniazid, rifampicin, pyrazinamide, and ethambutol). The patient is now 18 months after surgery with no recurrence. Extensor tendon transfer is planned.

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Fig. 1 Clinical appearance at the time of presentation to the author and magnetic resonance imaging (MRI) showing a fungoid stage of the disease on the ulnar side (large arrow) and a fibrinous stage with rice bodies on the radial side (small arrow).
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Fig. 2 (A) Intraoperative view showing the thickened tenosynovium (large arrow) and the rice bodies (small arrow). (B) Appearance after completion of the tenosynovectomy. The top arrow shows the area of loss of 50% of the width of the extensor tendon of the ring finger. The lower arrow shows the disrupted extensor digitorum tendon of the little finger. Note the intact extensor digiti minimi tendon (just ulnar to the disrupted extensor digitorum tendon).

Tendon rupture in tuberculous tenosynovitis is very rare and there are only few cases in the world lilterature. All previously reported cases with tendon rupture presented with primary tendon rupture (prior to surgery). In our case, there was primary rupture of the extensor carpi ulnaris. However, rupture of the extensor tendon of the ring finger occurred at 1 month after surgery. In traumatic partial extensor tendon lacerations involving 50 to 80% of the width of the tendon are treated conservatively with immediate postoperative physiotherapy, with an excellent outcome in all cases.[4] In our case, the loss from the extensor tendon of the ring finger involved 50% of the width of the tendon, but delayed rupture occurred. This may be related to the fact that the tendon in our case was a “diseased” and not a “traumatized healthy” tendon.

Another observation is that all previously reported cases with ruptured tendons in tuberculosis of the hand had advanced disease (in the fungoid stage).[1] [2] [5] This observation was also noted in our case and has not been mentioned in the literature on tuberculosis of the hand.



Publication History

Article published online:
13 August 2020

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