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Oxytocin-induced tenosynovitis and extensor digitorum tendon rupture
Vol. 14A, No.5 September 1989
9.
10.
II.
12.
13.
14.
fundus tendon of the ring finger secondary to ancient fracture of the hook of the hamate. J Bone Joint Surg 1974;56A: 1076-8. Minami A, Ogino T, Usui M, Ishii S. Finger tendon rupture secondary to fracture of the hamate. Acta Orthop Scand 1985;56:96-7. Stem PJ. Multiple flexor tendon ruptures following an old anterior dislocation of the lunate. J Bone Joint Surg 1981;63A:489-90. Vaughan-Jackson OJ. Rupture of extensor tendons by attrition of the inferior radioulnar joint. Report of two cases. J Bone Joint Surg 1948;30B:528-30. Speed K. Traumatic injuries of the carpus. Including Colles' fracture. New York: Appleton-Century-Crofts, 1925. MacAusland WR. Perilunar dislocation of the carpal bones and dislocation of the lunate bone. Surg Gynecol Obstet 1944;79:256-6. Aitken AP, Nalebuff EA. Volar transnavicular perilunar
Rupture of extensor tendons associated with PLD
15.
16.
17. 18. 19. 20.
dislocation of the carpus. J Bone Joint Surg 1960; 42A:1051-7. Campbell RD, Jr, Thompson TC, Lance EM, Adler JB. Indications for open reduction of lunate and perilunate dislocation of the carpal bones. J Bone Joint Surg 1965;47A:915-37. Woodward AH, Naviaser RJ, Nisenfeld F. Radial and volar perilunar transscaphoid fracture dislocation. South Med J 1975;68:926-8. Poumaras J, Kappas A. Volar perilunar dlslocation-s-a case report. J Bone Joint Surg 1979;6IA:625 -6. Green DP.. O'Brien ET. Classification and management of carpal dislocation. Clin Orthop 1980;149:55-72. SaunierJ, Chamay A. Volar perilunar dislocation of the wrist. Clin Orthop 1981;157:139-42. Fernandes HJA, Koberle G, Ferreira GFS, Camargo JN, Jr. Volar transscaphoid perilunar dislocation. Hand 1983;15:276-80.
Oxytocin-induced tenosynovitis and extensor digitorum tendon rupture A rare case of aseptic tenosynovltls from oxytocin injection in the vicinity of a tendon causing spontaneous rupture of the extensor digitorum communis tendon is reported. J HAND SURG 1989;14A:847-9.)
Santosh Rath, MS, Sydney, Australia, and Surya Bhan, MS, FRCS (Edin), New Delhi, India
Besides rheumatoid disease the most common cause of attrition and spontaneous rupture of tendons is local infiltration of hydrocortisone and related compounds in the vicinity of a tendon. 1-1 No other From the Hand Unit, Sydney Hospital , Sydney. Australia; and the Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India. Received for publication March 16, 1988; accepted in revised form Sept. 29, 1988. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: S. Bhan, MS, FRCS (Edin), Department of Orthopaedics , All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
3/1/13465
hormone or related drug has been known to produce attrition and rupture of tendons. Rare causes of tendon rupture are acute suppurative, and certain chronic, infections' and friction over a bony prominence after fracture." We report a case of rupture of extensor digitorum communis tendon caused by reactive tenosynovitis occurring as a result of extravasation of oxytocin during an intravenous infusion.
Case report A 28-year-old woman had venipuncture on the dorsum of her right hand for intravenous administration of oxytocin diluted with saline solution, during treatment for inevitable abortion . One hour later swelling was noticed on the dorsum of the hand caused by extravasation of the oxytocin solution. The dorsal swelling of the hand gradually increased over the
THE JOURNAL OF llANO SURGERY
847
848
The Journal of HAND SURGERY
Rath and Bhan
Fig. 1. The right hand shows dorsal swelling and inability to extend the metacarpophalangeal joint of the ring finger.
Fig. 2. Eight weeks after operation, the healed scar on dorsum of the hand is visible.
next 5 days and became painful. There was no fever and no systemic or local signs of infection. In the following week the pain gradually subsided but 3 weeks after the intravenous infusion, the patient noticed inability to actively extend her ring finger. Examination showed moderate swelling over the dorsum of the hand extending from the base of the metacarpals to their necks (Fig. 1). The area of swelling was indurated but had no appreciable tenderness and local temperature was not
Fig. 3. Photomicrograph of specimen of excised synovium shows infiltration of round cells. (Hematoxylin and eosin stain. Original magnification x40.)
raised. The metacarpophalangeal joint of the ring finger could not be actively extended; the other fingers had full active mobility. The extensor tendons were explored through a dorsal longitudinal incision. The swelling contained only about 5 ml of straw-colored fluid from which no microorganisms were grown. Synovium around the extensor digitorum tendons were hypertrophic and pale colored. The slips of extensor digitorum communis to index, ring, and small fingers were completely ruptured whereas the slip to the long finger was partially ruptured. Tendon ends were frayed and retracted. The extensor indicis and extensor digiti minimi tendons were intact and normal. The thickened synovium was excised. Because of fraying of the tendon ends, direct suture was not possible. The distal slips of the extensor tendons of the index and little fingers were joined to the extensor indicis and extensor digiti minimi tendons respectively. The partial rupture of the long finger tendon was repaired with fine Prolene sutures and was attached to the distal part of the extensor tendon of the ring finger. The hand was immobilized for 4 weeks, followed by gradual physiotherapy. Eight weeks after operation the patient had full active movements of all finger joints and the wound had healed uneventfully (Fig. 2). No antibiotics were given after operation. Histologic examination of the excised synovium showed inflammatory round cells infiltrating the synovium (Fig. 3). The tendon itself was of normal structure and did not show fatty degeneration or cellular infiltration. Three years later the patient remains well and has full function and mobility in her fingers.
Discussion Steroid injection in the vicinity of a tendon produces marked reduction in its tensile strength," degeneration of muscle, and fatty round cell infiltration." As a result of these changes the tendon undergoes attrition and
Vol. 14A, No.5 September 1989
Oxytocin-induced tenosynovitis and extensor digitorum tendon rupture
rupture. In this case the pathologic changes were different. Extravasation of the oxytocin solution produced tenosynovitis, which with possible ischemic necrosis, caused attrition of the tendon and led to its rupture. Synovectomy and repair of the tendons produced lasting cure. The mechanism of tendon rupture is similar in patients of rheumatoid arthritis. Our search of the English-language literature failed to reveal any previous report of tendon rupture from aseptic tenosynovitis caused by oxytocin, which does not normally produce any local reaction in body tissues. REFERENCES 1. Lee HB. Avulsion and rupture of tendocalcaneus after injection of hydrocortisone. Br Med J 1957;2:394. 2. Cowen MA, Alexander S. Simultaneous bilateral rupture of achilles tendon due to triamcinolone. Br Mcd I 1961;1:1658.
3. Ismail AM, Balakrishnan R, Rajkumar MK. Rupture of patellar ligament after steroid infiltration. I Bone Joint Surg 1969;518:503-5. 4. Kleinmann M, Gross AE, Achilles tendon rupture following steroid injection. J Bone Joint Surg 1983;65A: 1345-7. 5. Turek SL. In: Orthopaedics-principles and their application. Philadelphia: 18 Lippincott Co, 1984:1034. 6. Adams IC. In: Outline of fractures. Edinburgh: Churchill Livingstone, 1978:I67. 7. Wrenn RN, Goldner JL, Markee IC. An experimental study of the effect of cortisone on the healing process and tensile strength of tendons. J Bone Joint Surg 1954; 36A:588-60 I. 8. Salter RB, Murray D. Effect of hydrocortisone on rnusculoskeletal tissues. I Bone Joint Surg 1969;5IB:191.
Suppurative extensor tenosynovitis caused by Staphylococcus aureus Suppurative tenosynovitis is a rare infection, occurring almost exclusively in the flexor tendon sheath as a posttraumatic event, We report the case of a systemically ill woman with suppurative tenosynovitis of the extensor tendons caused by Staphylococcus aureus, Early recognition of this unusual infection may prevent unnecessary morbidity. (J HAND SURG 1989;14A:849-S1.)
Eric D. Newman, MD, Thomas M. Harrington, MD, FACP, Dennis Torretti, MD, and David C. Bush, MD, Danville, Pa.
Suppurative tenosynovitis is a rare infection whose poor prognosis was radically altered with the introduction of penicillin! and recognition of the need for surgical drainage.v' This infection almost al-
From the Department of Rheumatology and Orthopaedics, Geisinger Medical Center, Danville, Pa, Received for publication July 20, 1988; accepted in revised form Sept. 30, 1988. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Eric D. Newman, MD, Department of Rheumatology, Geisinger Medical Center, Danville, PA 17822. 3/1113469
ways involves the digital flexor tendon sheath. Only two other cases of well-documented extensor tendon suppurative tenosynovitis have been reported without a history of penetrating trauma. s, 6 We report a case of suppurative tenosynovitis involving the extensor tendons of the thumb caused by Staphylococcus aureus.
Case report A 57-year-old white woman with a history of juvenile onset diabetes mellitus, cervical cancer, and recurrent pyocystitis was wen until 5 days before admission when she fell, striking her left forearm and wrist. She developed a nonpainful ecchymosis in that area. One day before admission she was seen in the emergency room with pain and swelling of the left wrist. Examination revealed a temperature of 37.9° C, erythema and swelling overlying the first web space, and an THE JOURNALOF HANDSURGERY
849
9.
10.
II.
12.
13.
14.
fundus tendon of the ring finger secondary to ancient fracture of the hook of the hamate. J Bone Joint Surg 1974;56A: 1076-8. Minami A, Ogino T, Usui M, Ishii S. Finger tendon rupture secondary to fracture of the hamate. Acta Orthop Scand 1985;56:96-7. Stem PJ. Multiple flexor tendon ruptures following an old anterior dislocation of the lunate. J Bone Joint Surg 1981;63A:489-90. Vaughan-Jackson OJ. Rupture of extensor tendons by attrition of the inferior radioulnar joint. Report of two cases. J Bone Joint Surg 1948;30B:528-30. Speed K. Traumatic injuries of the carpus. Including Colles' fracture. New York: Appleton-Century-Crofts, 1925. MacAusland WR. Perilunar dislocation of the carpal bones and dislocation of the lunate bone. Surg Gynecol Obstet 1944;79:256-6. Aitken AP, Nalebuff EA. Volar transnavicular perilunar
Rupture of extensor tendons associated with PLD
15.
16.
17. 18. 19. 20.
dislocation of the carpus. J Bone Joint Surg 1960; 42A:1051-7. Campbell RD, Jr, Thompson TC, Lance EM, Adler JB. Indications for open reduction of lunate and perilunate dislocation of the carpal bones. J Bone Joint Surg 1965;47A:915-37. Woodward AH, Naviaser RJ, Nisenfeld F. Radial and volar perilunar transscaphoid fracture dislocation. South Med J 1975;68:926-8. Poumaras J, Kappas A. Volar perilunar dlslocation-s-a case report. J Bone Joint Surg 1979;6IA:625 -6. Green DP.. O'Brien ET. Classification and management of carpal dislocation. Clin Orthop 1980;149:55-72. SaunierJ, Chamay A. Volar perilunar dislocation of the wrist. Clin Orthop 1981;157:139-42. Fernandes HJA, Koberle G, Ferreira GFS, Camargo JN, Jr. Volar transscaphoid perilunar dislocation. Hand 1983;15:276-80.
Oxytocin-induced tenosynovitis and extensor digitorum tendon rupture A rare case of aseptic tenosynovltls from oxytocin injection in the vicinity of a tendon causing spontaneous rupture of the extensor digitorum communis tendon is reported. J HAND SURG 1989;14A:847-9.)
Santosh Rath, MS, Sydney, Australia, and Surya Bhan, MS, FRCS (Edin), New Delhi, India
Besides rheumatoid disease the most common cause of attrition and spontaneous rupture of tendons is local infiltration of hydrocortisone and related compounds in the vicinity of a tendon. 1-1 No other From the Hand Unit, Sydney Hospital , Sydney. Australia; and the Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India. Received for publication March 16, 1988; accepted in revised form Sept. 29, 1988. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: S. Bhan, MS, FRCS (Edin), Department of Orthopaedics , All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
3/1/13465
hormone or related drug has been known to produce attrition and rupture of tendons. Rare causes of tendon rupture are acute suppurative, and certain chronic, infections' and friction over a bony prominence after fracture." We report a case of rupture of extensor digitorum communis tendon caused by reactive tenosynovitis occurring as a result of extravasation of oxytocin during an intravenous infusion.
Case report A 28-year-old woman had venipuncture on the dorsum of her right hand for intravenous administration of oxytocin diluted with saline solution, during treatment for inevitable abortion . One hour later swelling was noticed on the dorsum of the hand caused by extravasation of the oxytocin solution. The dorsal swelling of the hand gradually increased over the
THE JOURNAL OF llANO SURGERY
847
848
The Journal of HAND SURGERY
Rath and Bhan
Fig. 1. The right hand shows dorsal swelling and inability to extend the metacarpophalangeal joint of the ring finger.
Fig. 2. Eight weeks after operation, the healed scar on dorsum of the hand is visible.
next 5 days and became painful. There was no fever and no systemic or local signs of infection. In the following week the pain gradually subsided but 3 weeks after the intravenous infusion, the patient noticed inability to actively extend her ring finger. Examination showed moderate swelling over the dorsum of the hand extending from the base of the metacarpals to their necks (Fig. 1). The area of swelling was indurated but had no appreciable tenderness and local temperature was not
Fig. 3. Photomicrograph of specimen of excised synovium shows infiltration of round cells. (Hematoxylin and eosin stain. Original magnification x40.)
raised. The metacarpophalangeal joint of the ring finger could not be actively extended; the other fingers had full active mobility. The extensor tendons were explored through a dorsal longitudinal incision. The swelling contained only about 5 ml of straw-colored fluid from which no microorganisms were grown. Synovium around the extensor digitorum tendons were hypertrophic and pale colored. The slips of extensor digitorum communis to index, ring, and small fingers were completely ruptured whereas the slip to the long finger was partially ruptured. Tendon ends were frayed and retracted. The extensor indicis and extensor digiti minimi tendons were intact and normal. The thickened synovium was excised. Because of fraying of the tendon ends, direct suture was not possible. The distal slips of the extensor tendons of the index and little fingers were joined to the extensor indicis and extensor digiti minimi tendons respectively. The partial rupture of the long finger tendon was repaired with fine Prolene sutures and was attached to the distal part of the extensor tendon of the ring finger. The hand was immobilized for 4 weeks, followed by gradual physiotherapy. Eight weeks after operation the patient had full active movements of all finger joints and the wound had healed uneventfully (Fig. 2). No antibiotics were given after operation. Histologic examination of the excised synovium showed inflammatory round cells infiltrating the synovium (Fig. 3). The tendon itself was of normal structure and did not show fatty degeneration or cellular infiltration. Three years later the patient remains well and has full function and mobility in her fingers.
Discussion Steroid injection in the vicinity of a tendon produces marked reduction in its tensile strength," degeneration of muscle, and fatty round cell infiltration." As a result of these changes the tendon undergoes attrition and
Vol. 14A, No.5 September 1989
Oxytocin-induced tenosynovitis and extensor digitorum tendon rupture
rupture. In this case the pathologic changes were different. Extravasation of the oxytocin solution produced tenosynovitis, which with possible ischemic necrosis, caused attrition of the tendon and led to its rupture. Synovectomy and repair of the tendons produced lasting cure. The mechanism of tendon rupture is similar in patients of rheumatoid arthritis. Our search of the English-language literature failed to reveal any previous report of tendon rupture from aseptic tenosynovitis caused by oxytocin, which does not normally produce any local reaction in body tissues. REFERENCES 1. Lee HB. Avulsion and rupture of tendocalcaneus after injection of hydrocortisone. Br Med J 1957;2:394. 2. Cowen MA, Alexander S. Simultaneous bilateral rupture of achilles tendon due to triamcinolone. Br Mcd I 1961;1:1658.
3. Ismail AM, Balakrishnan R, Rajkumar MK. Rupture of patellar ligament after steroid infiltration. I Bone Joint Surg 1969;518:503-5. 4. Kleinmann M, Gross AE, Achilles tendon rupture following steroid injection. J Bone Joint Surg 1983;65A: 1345-7. 5. Turek SL. In: Orthopaedics-principles and their application. Philadelphia: 18 Lippincott Co, 1984:1034. 6. Adams IC. In: Outline of fractures. Edinburgh: Churchill Livingstone, 1978:I67. 7. Wrenn RN, Goldner JL, Markee IC. An experimental study of the effect of cortisone on the healing process and tensile strength of tendons. J Bone Joint Surg 1954; 36A:588-60 I. 8. Salter RB, Murray D. Effect of hydrocortisone on rnusculoskeletal tissues. I Bone Joint Surg 1969;5IB:191.
Suppurative extensor tenosynovitis caused by Staphylococcus aureus Suppurative tenosynovitis is a rare infection, occurring almost exclusively in the flexor tendon sheath as a posttraumatic event, We report the case of a systemically ill woman with suppurative tenosynovitis of the extensor tendons caused by Staphylococcus aureus, Early recognition of this unusual infection may prevent unnecessary morbidity. (J HAND SURG 1989;14A:849-S1.)
Eric D. Newman, MD, Thomas M. Harrington, MD, FACP, Dennis Torretti, MD, and David C. Bush, MD, Danville, Pa.
Suppurative tenosynovitis is a rare infection whose poor prognosis was radically altered with the introduction of penicillin! and recognition of the need for surgical drainage.v' This infection almost al-
From the Department of Rheumatology and Orthopaedics, Geisinger Medical Center, Danville, Pa, Received for publication July 20, 1988; accepted in revised form Sept. 30, 1988. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Eric D. Newman, MD, Department of Rheumatology, Geisinger Medical Center, Danville, PA 17822. 3/1113469
ways involves the digital flexor tendon sheath. Only two other cases of well-documented extensor tendon suppurative tenosynovitis have been reported without a history of penetrating trauma. s, 6 We report a case of suppurative tenosynovitis involving the extensor tendons of the thumb caused by Staphylococcus aureus.
Case report A 57-year-old white woman with a history of juvenile onset diabetes mellitus, cervical cancer, and recurrent pyocystitis was wen until 5 days before admission when she fell, striking her left forearm and wrist. She developed a nonpainful ecchymosis in that area. One day before admission she was seen in the emergency room with pain and swelling of the left wrist. Examination revealed a temperature of 37.9° C, erythema and swelling overlying the first web space, and an THE JOURNALOF HANDSURGERY
849