Synovial Sheath Research Articles

Treatment of a Little Finger Synovial Cyst by Repair of an Opening in the Wrist Capsule: Case Report

As synovial fluid from the wrist may leak into the ulnar bursa and from there into the flexor synovial sheath in the little finger, the origin of a synovial cyst of the pulp of the little finger may be in the wrist. Here we present the surgical treatment of a patient with a synovial cyst of the pulp of the little finger by surgery of the wrist and palm of the hand after failed conservative treatment.

Lipoma Arborescens of the Peroneus Longus and Peroneus Brevis Tendon Sheath

Lipoma arborescens is an uncommon pseudotumoral synovial lesion usually located in the suprapatellar pouch of the knee. Lipoma arborescens involving the synovial sheaths of the tendons is exceedingly rare. This diagnosis should be considered, particularly in patients with chronic joint effusion. We report a case with lipoma arborescens affecting the synovial sheaths of the peroneal tendons without involvement of the adjacent ankle joint. To our knowledge, this is the second reported case of lipoma arborescens involving tenosynovial sheaths of tendons around the ankle joint without ankle joint involvment.

A Case of Antibiotic-Resistant Dorsal Hand Purulent Tenosynovitis Diagnosed by Ultrasound Post Liver Transplant

Tenosynovitis is an inflammation of the synovial sheath surrounding a tendon. This may be caused by a variety of etiological factors. Here we describe the case of a 40 year old diabetic patient who two months after liver transplantation developed left-hand purulent tenosynovitis. Tenosynovitis was diagnosed using ultrasound, found to be caused by cryptococcus neoformans, and successfully treated using antifungal therapy combined with ultrasound follow-up.

Haemangioma in relation to the synovium of the sheath of the Flexor Pollicis Longus

Haemangioma of the tendon sheaths in thumb is rare. We report a case of a 15 year old girl with a slowly growing, painful haemangioma of the synovium of tendon sheath of Flexor Pollicis Longus of her dominant hand in which the tumour had not infiltrated the tendon. CASE HISTORY A 15 year old girl came to our hospital with complaints of a painful swelling on the inner aspect of her right thumb. She had noticed the swelling 5 months back but the pain had started only one month back. The swelling was slowly growing in size. It was present on the medial half of the thumb. The skin over the swelling had a bluish hue. The swelling was tender though the phalanges were non-tender on palpation of their lateral aspects. It was slightly compressible on pressure. Flexion at interphalangeal joint was painful. Rest of the movements at the thumb were full range and pain free. Radiographs showed no bony lesion but a soft tissue shadow as expected. She was diagnosed as a case of Haemangioma and admitted for excisional biopsy. On surgical exploration the tumour was seen as dark red fleshy mass originating from the tendon sheath of flexor pollicis longus (Fig 1 and Fig 2). The tendon itself was not infiltrated by the tumour. The tumour along with the tendon sheath was excised without sacrificing the tendon (Fig 3). Biopsy of the swelling confirmed the diagnosis of Haemangioma. Figure 1 Figure 1 Haemangioma in relation to the synovium of the sheath of the Flexor Pollicis Longus 2 of 3 Figure 2 Figure 2 Figure 3 Figure 3 DISCUSSION Haemangioma in relation to tendon sheaths in thumb is very rare. Only a few cases have been reported in literature with Haemangioma in relation to tendon sheaths in hand. Only one case has been reported with tumour infiltrating the tendon1. The cases without tendon infiltration are completely resected with functional recovery2. The recent haemorrhage corresponds to the sudden increase in size, while the papillary endothelial hyperplasia accounts for the persistence and gradual enlargement of the lesion3. CORRESPONDENCE TO Abid Hussain Koka. Flat no. 10. Govt. flats Jawaharnagar Srinagar, Near SBI. JK71(5):618-21. 2. Rico AA, Holguin PH, Gonzalez IG, Coba JM. Flexor tendon synovial sheath haemangioma mimicking subacute tenosynovitis. J Hand Surg [Br]. 1994 Dec;19(6):704-5. 3. Chow LT, Ho PC, Kumta SM. Papillary endothelial hyperplasia within synovial haemangioma of the flexor tendon sheath of the wrist. APMIS. 2004 Apr- May;112(4-5):314-8. Haemangioma in relation to the synovium of the sheath of the Flexor Pollicis Longus 3 of 3 Author Information Abid Hussain Koka, MS (Orthopaedics) Senior resident, Department of Orthopaedics, SKIMS Medical College Simon Desouza Paljor, MS (Orthopaedics) Department of Orthopaedics, SKIMS Medical College Talib Khan, MD (Anaesthesia) Department of Orthopaedics, SKIMS Medical College Moulvi Sajad, MS (Orthopaedics) Department of Orthopaedics, SKIMS Medical College

Quantifying normal ankle joint volume: An anatomic study

Background:Many therapeutic and diagnostic modalities such as intraarticular injections, arthrography and ankle arthroscopy require introduction of fluid into the ankle joint. Little data are currently available in the literature regarding the maximal volume of normal, nonpathologic, human ankle joints. The purpose of this study was to measure the volume of normal human ankle joints.Materials and Methods:A fluoroscopic guided needle was passed into nine cadaveric adult ankle joints. The needle was connected to an intracompartmental pressure measurement device. A radiopaque dye was introduced into the joint in 2 mL boluses, while pressure measurements were recorded. Fluid was injected into the joint until three consecutive pressure measurements were similar, signifying a maximal joint volume.Results:The mean maximum ankle joint volume was 20.9 ± 4.9 mL (range, 16–30 mL). The mean ankle joint pressure at maximum volume was 142.2 ± 13.8 mm Hg (range, 122–166 mm Hg). Two of the nine samples showed evidence of fluid tracking into the synovial sheath of the flexor hallucis longus tendon.Conclusion:Maximal normal ankle joint volume was found to vary between 16–30 mL. This study ascertains the communication between the ankle joint and the flexor hallucis longus tendon sheath. Exceeding maximal ankle joint volume suggested by this study during therapeutic injections, arthrography, or arthroscopy could potentially damage the joint.

Screw Impingement on the Extensor Tendons in Distal Radius Fractures Treated by Volar Plating: Sonographic Appearance

The objective of our study was to analyze the sonography examinations of nine consecutive patients with a history of distal radius fracture treated by open reduction and internal fixation of the volar plate who were referred by hand surgeons for sonography of the dorsal aspect of the wrist. We postulate that impingement of the extensor tendons in patients with distal radius fracture treated by volar plating starts with local hyperemia and is followed by tenosynovitis and, finally, by partial and complete tendon tears. Sonography is an effective, dynamic, and noninvasive technique with which to diagnose and evaluate damage to the extensor tendons and their synovial sheaths.

Apport de l’échographie dans la prise en charge de la ténosynovite de de Quervain : à propos de 22 cas

To assess the role of US in the management of de Quervain's tenosynovitis. Using a high-frequency transducer (12 MHz), sagittal and axial images were obtained of the first extensor compartment. The US features of 22 symptomatic patients were reviewed (positive Finkelstein's maneuver). US findings included tendon thickening and synovial sheath thickening with peritendinous edematous changes resulting in a peritendinous hypoecoic halo in all patients. An intertendinous septum was identified in two patients. US can confirm the suspected diagnosis and provide follow-up of lesions. It can confirm the presence of an intertendinous septum and provide guidance at the time of steroid injection. It can increase the rate of conservative management by demonstrating the absence of septum.

The accumulation of inflammatory cells in synovial sheath and epitenon during adhesion formation in healing rat flexor tendons.

The accumulation of inflammatory cells in synovial tissue was studied using indirect immunofluorescence assays on cell cultures and frozen tissue sections of healing rat digital flexor tendons. Flexor tendons were collected from rats 3, 7 and 14 days after crush injury. Tendon sheath and epithenon cells were isolated by sequential enzymic digestion and cultured for 2 days. Subpopulations of synovial and inflammatory cells were identified with MoAbs against cell surface glycoproteins present on B lymphocytes (CD45), T lymphocytes (CD2, CD4, CD8), macrophages (CD14) and endothelial cells. A phagocytosis assay was also used to identify macrophages. We report a substantial increase in the number of T lymphocytes (mainly helper/inducer) and phagocytotic cells with monocyte/macrophage surface markers in tendon sheath and epitenon 3 days after crush injury. The infiltration of inflammatory cells into synovial sheath and epitenon preceded an increase in fibronectin production by tendon cells which was seen 7 days after injury. To study the interaction between T lymphocytes and synovial cells in vitro, we established synovial fibroblast-like type B cell cultures and used stimulated and non-stimulated T lymphocytes in cell binding assays. We observed increased adhesiveness between unstimulated synovial cells and synovial cells previously cultured with activated and non-activated T lymphocytes. ELISA inhibition studies have shown an increase in fibronectin production by synovial fibroblasts co-cultured with stimulated CD4+ T lymphocytes. We suggest that the presence of inflammatory cells in synovial sheath and epitenon during tendon healing induces synovial fibroblasts and epitenon cells to increase their production of fibronectin, which provides a scaffold for subsequent adhesion formation.

Fast spin echo-T2-weighted sequences with fat saturation in toe dactylitis of spondyloarthritis

We aimed to establish by using fast spin echo (FSE)-T2-weighted sequences with fat saturation if flexor tendon enthesitis is the primary lesion in spondyloarthritis (SpA) toe dactylitis. Consecutive patients showing toe dactylitis and meeting Amor criteria for the classification of SpA were enrolled. Dactylitic toes and their corresponding normal contralateral digits were studied by FSE-T2-weighted sequences with fat saturation. Twelve dactylitic toes belonging to ten SpA patients were studied. All dactylitic toes showed mild-to-moderate fluid collection in the synovial sheaths of flexor digitorum brevis and longus. Involvement of joint cavity was simultaneously seen in at least one joint of eight (66.6%) out of the 12 toes. A mild-to-severe peritendinous soft tissue edema was observed in all but one of the affected toes. In no dactylitic toe was bone edema observed either near the insertions of the flexor digitorum brevis and longus tendons or in other sites of the phalanges. No lesions were observed in the 12 contralateral clinically normal toes. In SpA toe dactylitis there is no evidence of enthesitis of the flexor digitorum brevis and longus tendons and joint capsules.

Results of histological studies of the flexor tendon sheath in 35 flexor tenosynovectomies in carpal tunnel syndrome

This paper presents the results of histologic studies conducted in the context of tenosynovectomy of the flexor tendons to treat carpal tunnel syndrome. The most common findings were inflammatory changes of the synovial sheath, vascular pathology and fibrous changes of the connective tissue.

Propriozeption im vorderen Kreuzband des menschlichen Kniegelenkes - morphologische Grundlagen

In 21 human anterior cruciate ligaments removed with their synovial sheaths during autopsy and operation, nerves and nerve endings were demonstrated by light microscopy, scanning electron microscopy and transmission electron microscopy. Ultrastructural examination allowed a classification of nerve endings into three types: Ruffinian corpuscles, Pacinian corpuscles and free (afferent and efferent) nerve endings. The nerve endings corresponded to those characteristic of articular capsules. The anterior cruciate ligament shows evidence of a proprioceptive function besides its stabilizing function, which is based on its collagenous structure. Together, they probably represent the most important factor in the dynamic stabilization of the knee joint. At present it is only possible to speculate on the potential clinical significance of these findings, for example in development of rehabilitation programs and prevention strategies offering protection against anterior cruciate tears. This also applies to the question of whether to preserve the ligament during surgery for ruptures and knee-joint prostheses.

Synovial and tenosynovial lipoma arborescens of the ankle in an adult: a case report

Lipoma arborescens is a rare benign fat-containing synovial proliferative lesion that is typically known to affect the knee joint in adults. We present the first case of lipoma arborescens of the ankle joint in an adult patient with involvement of the intra-articular synovium as well as the synovial sheath of the tendons around the ankle. The MRI features of this lesion in the adult ankle are described.

CT Guided Aspiration of a Cervical Synovial Cyst

Synovial cysts are cystic dilations of synovial sheaths with or without anatomical continuity within a joint space that occasionally involve the lumbar spine. Image-guided aspiration has been used successfully in the management of lumbar synovial cysts. Synovial cysts of the cervical spine are rare, tend to present with myelopathic symptoms, and are classically treated using operative intervention.We report a novel approach for cervical synovial cyst aspiration under CT guidance. A 66-year-old woman presented to the clinic complaining of severe pain, tingling, and dysesthesia in her right upper extremity in the C5, C6 and C7 nerve root distribution. MR imaging of her cervical spine showed a synovial cyst within the right C6-C7 neural foramen with significant compression and obliteration of the C7 nerve root. The patient underwent CT-guided aspiration of the cyst using a double needle technique, where one needle was used to open up the epidural space while another aspirated the cyst. This was followed by epidural injection of local anesthetic and steroids. Immediately after injection, the patient experienced complete relief of her right forearm pain, tingling, and dysesthesias. The patient tolerated the procedure well and there were no postprocedure complications. At four year follow-up the patient is free of any symptoms. Image-guided aspiration of cervical synovial cysts is feasible using CT fluoroscopy. Aspiration of these cysts combined with epidural steroid injection can provide long-lasting symptomatic relief in some patients.

Ultrasound imaging of non-traumatic lesions of wrist and hand tendons

Non-traumatic tendon lesions are common and diverse at the wrist and hand. Improvements in high-resolution ultrasound (US) are producing increasingly high-quality images of superficial structures, thus expanding the indications for this imaging modality as a tool for investigating musculoskeletal disorders. The objective of this work is to provide an update on the uses and performance of US in non-traumatic tendon disorders of the wrist and hand. The relevant anatomy is reviewed, and the normal and abnormal ultrasound scan features are described in detail, with attention not only to the tendons but also to closely related structures such as synovial sheaths and bands. The contribution of US to the evaluation of each of the most common disorders is discussed.

Collagen Structure of Tendon Relates to Function

A tendon is a tough band of fibrous connective tissue that connects muscle to bone, designed to transmit forces and withstand tension during muscle contraction. Tendon may be surrounded by different structures: 1) fibrous sheaths or retinaculae; 2) reflection pulleys; 3) synovial sheaths; 4) peritendon sheaths; 5) tendon bursae. Tendons contain a) few cells, mostly represented by tenoblasts along with endothelial cells and some chondrocytes; b) proteoglycans (PGs), mainly decorin and hyaluronan, and c) collagen, mostly type I. Tendon is a good example of a high ordered extracellular matrix in which collagen molecules assemble into filamentous collagen fibrils (formed by microfibrils) which aggregate to form collagen fibers, the main structural components. It represents a multihierarchical structure as it contains collagen molecules arranged in fibrils then grouped in fibril bundles, fascicles and fiber bundles that are almost parallel to the long axis of the tendon, named as primary, secondary and tertiary bundles. Collagen fibrils in tendons show prevalently large diameter, a D-period of about 67 nm and appear built of collagen molecules lying at a slight angle (< 5). Under polarized light microscopy the collagen fiber bundles appear crimped with alternative dark and light transverse bands. In recent studies tendon crimps observed via SEM and TEM show that the single collagen fibrils suddenly changing their direction contain knots. These knots of collagen fibrils inside each tendon crimp have been termed “fibrillar crimps”, and even if they show different aspects they all may fulfil the same functional role. As integral component of musculoskeletal system, the tendon acts to transmit muscle forces to the skeletal system. There is no complete understanding of the mechanisms in transmitting/absorbing tensional forces within the tendon; however it seems likely that a flattening of tendon crimps may occur at a first stage of tendon stretching. Increasing stretching, other transmission mechanisms such as an interfibrillar coupling via PGs linkages and a molecular gliding within the fibrils structure may be involved.

A Novel Approach to Flexor Hallucis Longus Tenography

This article presents a technically simple and more accurate approach to flexor hallucis longus (FHL) tenography than any we found reported in the literature. Tenography is used to evaluate and treat tenosynovitis. Standard FHL tenography protocol involves either direct percutaneous access of the FHL synovial sheath posterior to the medial malleolus or indirect filling of the FHL sheath from an injection of the flexor digitorum longus (FDL) tendon sheath, which often communicates with the FHL tendon sheath. However, with these methods, difficulty entering the FHL sheath may be encountered. We adapted our technique to access the FHL sheath as it courses below the sustentaculum talus. Our early experience with five cases using this technique reflects a 100% success rate with accurate needle placement within the FHL tendon sheath, thereby improving procedural efficiency.

Ténosynovite tuberculeuse : une localisation rare

Introduction Synovial sheath involvement of the foot is a rare location of tuberculosis. Its diagnosis is often delayed because of the indolent and chronicity of the clinical features. Observation We report a case of bilateral tuberculous tenosynovitis of the anterior tibial and the common extensor of the toes, with uneventful outcome with antituberculous therapy. Conclusion Tuberculous tenosynovitis is uncommon but should be kept in mind in chronic tenosynovitis.

Microscopic and histological examination of the mouse hindpaw digit and flexor tendon arrangement with 3D reconstruction

Mice are currently the species of choice for the in vivo study of injury, but few detailed anatomical descriptions have been made of rodent digits, limiting their use for the investigation of intrasynovial tendon healing. In this study a detailed microscopic and histological investigation was performed using C57/BL6 and Tie2 LacZ reporter gene transgenic mice. Serial-sectioned mouse hindpaw digits were characterized using haematoxylin and eosin, Masson's trichrome (collagen), Alcian blue (fibrocartilage), Miller's stain (elastin) and TRITC-phalloidin (cellular cytoskeleton) staining. Digital vasculature was demonstrated using FITC-labelled dextran perfusion studies supplemented with LacZ expression in Tie2 LacZ transgenic mice digits. Imaging of the digit used a combination of brightfield and confocal microscopy with three-dimensional reconstruction. Our findings demonstrated that the mouse hindpaw possesses deep and superficial flexor tendons within a synovial sheath comparable with that found in other mammalian species. The intrasynovial tendons were avascular and had regions of fibrocartilaginous specialization relating to areas of compression. Corresponding vascular networks were demonstrated around the sheath using Tie2 LacZ mice and FITC-perfused hindpaws. Furthermore, there is an area of digit where both deep and superficial tendons reside between two pulleys, similar to zone 2 in the human hand where it would be possible to study intrasynovial tendon injury and adhesion formation. In conclusion, although the dimensions of the mouse digit pose technical challenges for surgical intervention, we have identified a model for the study of flexor tendon injury that will permit future genetic manipulation studies.

Rice-Body Formation and Tenosynovitis of the Wrist: A Case Report

A 61-year-old woman presented with mild pain and swelling on the volar aspect of the wrist, hand, and little finger. Radiography showed a soft-tissue mass shadow, and magnetic resonance imaging showed acute tenosynovitis of the flexor tendons and an inflammatory mass inside the carpal tunnel. Laboratory test results were normal, except for an elevated erythrocyte sedimentation rate (40 mm/h). The patient had an ambiguous Mantoux test result but no history of mycobacterial exposure. Exhaustive investigations for rheumatic disease were negative. Surgical exploration of the lesion revealed rice bodies in the common flexor tendon synovial sheath, extending distally to the tip of the fifth finger. Removal of the rice bodies and thorough excision of the sheath was performed. The patient regained a full and painless range of motion in about 3 months. One-year follow-up revealed no underlying disorder.

Radial and ulnar neuropathy due to pigmented villonodular synovitis of the elbow

a igmented villonodular synovitis (PVNS) is a benign, roliferative disorder that affects synovial tissue, burae, and tendon sheaths. It presents in 2 different orms: diffuse and focal. The diffuse form typically ffects the entire synovial lining of large joints, hereas the focal form occurs in small joints. The nnual incidence is approximately 1.8 cases per milion persons. PVNS most commonly occurs in paients aged between 30 and 50 years. There is no ender bias in its occurrence. It is predominantly ound in the knee and hip and is less common in the nkle, shoulder, and wrist. The prevalence of PVNS of he elbow is rare. Less than 25 cases of PVNS of the lbow have been reported. To our knowledge, no case of neuropathy due to VNS of the elbow has been described in the literature. e report a unique case of extraarticular PVNS of the lbow seen with radial and ulnar neuropathy and disuss its cause, pathophysiology, and treatment.