Tenosynovial haemangioma of the finger

Haemangiomas developing in the hand in relation to tendon and the tenosynovium (tendon sheath) are very rare. To our knowledge only three cases have been described arising in relation to the tenosynovium of the tendons of the hand, only one of which showed infiltration of the underlying tendon. We report the case of a 16-year-old right hand dominant student who presented to her family doctor with a swelling on her left little finger. An MRI scan was arranged which confirmed a soft tissue lesion between the flexor tendons and the proximal phalanx of the left little finger, with appearance similar to giant cell tumour of the tendon sheath. Surgical exploration demonstrated a dark red fleshy tumour that appeared to infiltrate the flexor digitorum sub-limis tendon, and extend around either side of the proximal phalanx. For complete excision of the lesion the infiltrated sublimis tendon and a part of the A2 pulley were sacrificed. There was no resultant bow-stringing of the profundus tendon. Histologically the tenosynovium was expanded by a vascular lesion consisting of dilated, thin-walled vascular channels within fibrous tissue; the appearances were consistent with those of a synovial haemangioma of the flexor tendons. Our case illustrates the pitfalls in diagnosis and the invasive potential of a synovial haemangioma. A complete surgical excision is critical to prevent recurrence.     

The contents of macromolecule solutes in flexor tendon sheath fluid and their relation to synovial fluid. A quantitative analysis.

The importance of synovial environment for minimal adhesion formation in flexor tendon healing has recently gained attention. Various techniques have been used to restore an injured synovial tendon sheath. Therefore a quantitative analysis of flexor tendon sheath fluid is of interest to increase our knowledge about the specific synovial milieu and to evaluate the success of different types of sheath reconstructions from a biochemical point of view. Samples of tendon sheath fluid from trigger digits and tendon sheaths containing ganglions have been assayed for contents of hyaluronic acid and proteins of different molecular weights. The results show concentrations of hyaluronate and several proteins similar to those in normal joint fluid. These results indicate that flexor tendon sheath fluid has a character similar to synovial fluid of joints and apparently has specific functions such as soft tissue lubrication and nutrition of avascular tendon tissue.     

The Role of the Digital Synovial Sheath in Tendon Grafting: An Experimental and Clinical Study on Autologous Tendon Grafting in the Digit

The mechanism of healing of a free tendon graft and also the role played by the synovial sheath is still obscure and debated. In the present study an effort is made to further elucidate these problems. In rabbits and dogs an experimental model was developed where a free tendon graft would be nourished by synovial fluid only. Macroscopically the grafts remained smooth, white and glistening without vascular ingrowth or adhesions during an observation period of 12 weeks. By histological and histochemical techniques the grafts as a whole were found viable up to 3 weeks. In a clinical series of 40 free flexor tendon grafts within the digital area as much as possible of the tendon sheath was preserved during grafting. The functional recovery was generally very good. The best results were obtained in those cases where most of the tendon sheath was preserved. No signs of defective graft survival were observed. Based on both experimental and clinical results from the present study it is concluded that there is no reason to excise the remaining tendon sheath within the critical zone in the digits. On the contrary preservation of the sheath contributes to survival of the graft and helps maintaining the integrity of gliding surfaces with maximal functional restoration and minimal formation of adhesions.     

Flexor tendon nutrition

The concepts regarding nutrient pathways to flexor tendons within the digital sheath are reviewed. Historically, both diffusion and perfusion have been considered significant pathways to the flexor tendon. Theories of tendon healing and adhesion formation, as well as techniques employed by the surgeon in the repair of tendons, are based on these concepts.     

指背腱膜的解剖学研究

目的 探讨指背腱膜的构成特点及临床意义。方法 在30只成人尸体手标本上，通过模拟手术，对指背腱膜的构成特点进行了应用解剖学观测。结果 指背腱膜的构成复杂，其中的外侧腱束、外侧束、外侧腱和中央束在手指畸形的发生中有着特殊的临床意义。外侧腱束主要形成伸近节指间关节的功能解剖机制；其与外侧束形成的密切纤维联系而具有协同外侧腱的功能；该腱束与屈肌腱鞘有联系又使其具有平衡屈肌和伸肌肌力的作用。中央束在指背腱膜的整体协调、畸形的发生及矫正过程中起着重要的功能。结论 通过对指背腱膜的解剖研究，可以解释因指屈、伸肌腱平衡被破坏后所形成的畸形。     

Subcutaneous rupture of the flexor hallucis longus tendon: a case report

It is well known that rupture of the flexor hallucis longus tendon can be associated with open injuries and that closed rupture of the flexor hallucis longus tendon is rare. Tendon injuries of the foot can occur secondary to direct, indirect, or repetitive injury. Repetitive tendon injuries can cause tendinitis or stenosing tenosynovitis. Tendinitis is associated with internal tendon injury that can present with tendon thickening, mucinoid degeneration, nodule development, or in situ partial tears. Stenosing tenosynovitis is the development of tendon adhesions within the tendon sheath that interfere with tendon gliding, known as trigger toe. The flexor hallucis longus tendon is susceptible to injury along its entire course. A total of 35 cases of complete or partial closed ruptures of the flexor hallucis longus tendon have been reported. We present the case of complete subcutaneous rupture of the flexor hallucis longus tendon associated with trauma at the proximal phalangeal head.     

Eight-strand core suture technique for repair of intrasynovial flexor tendon lacerations

The concept of intrinsic tendon healing, the idea that tendons can heal primarily without the ingrowth of fibrous adhesions from the surrounding fibrous flexor sheath, has been validated both experimentally and clinically. The goals of the surgical treatment of intrasynovial digital flexor tendon lacerations are twofold: 1) to achieve a primary tendon repair of sufficient strength so as to prevent repair site gap elongation and possible rupture, and 2) to prevent the formation of intrasynovial adhesions that cause loss of tendon excursion within the flexor tendon sheath. It is well accepted that repair site strength, both at time zero and within the first 6 postoperative weeks, is directly related to the number of core suture strands crossing the repair site. The factor that limits more widespread use of multistrand suture techniques remains the surgeon's ability to perform the repair while also minimizing trauma to the tendon stumps and the circumferential epitenon. We describe an 8-strand core suture technique used at our institution that has been tested ex-vivo, in-vivo in canines, and used in human subjects over the last 4 years with excellent results.     

Bridge flexor tendon grafts

In adults, when flexor tendons cannot be repaired until weeks or months after injury or when tendons have ruptured and part of the tendon is nonviable, it is often inadvisable to suture the tendon ends together. When a primary repair has failed, when there has been a delay in tendon reconstruction to allow skin coverage or joint mobilization, or when repair has been delayed because of infection, continuity of a profundus tendon or flexor pollicis longus tendon can often be restored by using a free graft to bridge the defect. Many patients treated by this procedure will have a satisfactory result providing that the flexor tendon is undamaged within its digital sheath and the muscle is intact and has adequate amplitude. In the study reported here, satisfactory function was restored to 28 of 37 fingers and to eight of ten thumbs treated by this method.     

Die Beugesehnenscheideninfektion der Finger und des Daumens

Infections of the flexor tendon sheath must be quickly identified and specifically treated. The special anatomy of the flexor tendon sheath and spread of infection must be known as well as the clinical signs of a beginning infection, differential diagnoses, microbiology and perioperative management, such as anesthesia. Only by early treatment can a full recovery of hand function be achieved. Late or masked diagnoses often have unsatisfactory long-term results. Surgical treatment must address the specific infection and completely eliminate the infection if possible in one operation. The intraoperative findings of the flexor tendon are decisive for the surgical procedure. Rehabilitation after surgery for flexor tendon sheath infections plays a special role. The spectrum of complications of this disease is high but good and very good results have now been achieved with early treatment.     

Experimental tendon grafting within intact tendon sheath

A chicken toe experimental model was used to study the fate of flexor tendon grafts, introduced into intact tendon sheaths. After perfusion of the limb by India Ink, the vascular pattern of the graft and the synovial sheath could be identified. The grafts showed no or few adhesions to the sheath. With time, there was a conversion from a diffuse superficial vascular pattern towards a concentration of vessels on the dorsal aspect of the graft. In a control group, where the sheath had been resected, adhesions were more apparent, and could be observed still after 16 weeks. These results are in complete agreement with previous experimental findings and further confirm the importance of an intact tube system in the digit.     

Nutrient pathways to flexor tendons using hydrogen washout technique

The nutrient pathways of flexor tendons within the flexor sheath were studied using the hydrogen washout technique. Hydrogen uptake and decay of a free segment of flexor tendon detached from its blood supply were not significantly different from an intact tendon lying in the synovial bed. There was no hydrogen uptake by flexor tendons which were mechanically separated from the synovial bed, even though muscular, periosteal and vincular attachments were intact. We concluded from this study that the synovium of the flexor tendon was a significant nutrient pathway for the flexor tendon and that the blood vessels did not appear to play a significant role in the nourishment of the flexor tendon.     

Tendon injuries of the hand

Tendon injuries are the second most common injuries of the hand and therefore an important topic in trauma and orthopedic patients. Most injuries are open injuries to the flexor or extensor tendons, but less frequent injuries, e.g., damage to the functional system tendon sheath and pulley or dull avulsions, also need to be considered. After clinical examination, ultrasound and magnetic resonance imaging have proved to be important diagnostic tools. Tendon injuries mostly require surgical repair, dull avulsions of the distal phalanges extensor tendon can receive conservative therapy. Injuries of the flexor tendon sheath or single pulley injuries are treated conservatively and multiple pulley injuries receive surgical repair. In the postoperative course of flexor tendon injuries, the principle of early passive movement is important to trigger an "intrinsic" tendon healing to guarantee a good outcome. Many substances were evaluated to see if they improved tendon healing; however, little evidence was found. Nevertheless, hyaluronic acid may improve intrinsic tendon healing.     

Hyaluronic acid in flexor tendon sheath fluid after sheath reconstructions in rabbits. A comparison between tendon sheath transplantation and conventional two stage procedures

Because the synovial environment has been suggested to be important in limiting the number of postoperative adhesions after flexor tendon surgery, and a high concentration of hyaluronic acid is a characteristic feature of synovial fluid, we have examined the hyaluronic acid concentrations in fluid collected from different kinds of reconstructed flexor tendon sheaths in rabbits. The hyaluronic acid concentration in normal rabbit flexor tendon sheaths was similar to that in normal human sheath and joint fluid. Rabbit tendon sheaths restored by autologous sheath grafts and partial pseudosheaths contained similar or somewhat lower hyaluronic acid concentrations, whereas in complete pseudosheaths the concentrations were considerably lower. The data suggest that tendon sheath reconstructions should consist at least partly of synovial membrane so that they are as similar as possible to normal synovial membrane.     

Excursion of the flexor digitorum profundus tendon: a kinematic study of the human and canine digits

The most common problem following primary flexor tendon repair is the failure of the tendon apparatus to glide, secondary to the formation of adhesions. Early motion following tendon repair has been shown to be effective in reducing adhesions between the tendon and the surrounding sheath. Therefore, it is important to determine the amount of flexor tendon excursion along the digit during joint motion. In this study, the excursion between the flexor digitorum profundus (FDP) tendon and the sheath was examined in both human and canine digits. Based on roentgenographic measurements and joint kinematic analysis, the motion of the bones, the FDP tendon, and the sheath were measured with respect to joint rotations. It was found that the canine flexor tendon apparatus behaved similarly to that of the human for the motions studied. The amount of tendon excursion was very small in regions distal to the joint in motion (approximately 0.1 mm/10 degrees of joint rotation). There was little displacement of the sheath (0.2-0.3 mm), except at the metacarpal joint region during metacarpophalangeal (MCP) joint motion and at the proximal interphalangeal (PIP) joint region during PIP joint motion. Tendon excursion relative to the tendon sheath was the largest in zone II during PIP joint rotation (1.7 mm/10 degrees of joint rotation). These results suggest that PIP joint motion may be most effective in reducing adhesions following tendon repair in zone II.     

The effect of flexor sheath integrity on nutrient uptake by chicken flexor tendons

The effect of varying degrees of flexor sheath integrity (sheath excised, incised, or incised and repaired) on the uptake of 3H-proline by chicken flexor tendons in Zone II was studied. The tendons were either: normal and uninjured, lacerated and repaired, or uninjured except for vinculum longum ligation. Different degrees of sheath integrity did not influence the uptake of 3H-proline by the tendons. The tendon does not appear to be dependent on a synovial environment for nutrients and is capable of obtaining these nutrients by diffusion from the surrounding extracellular tissue fluid. Diffusion is the primary nutrient pathway to the flexor tendon in this area, because removing its major vascular attachment (i.e., the vinculum longum) did not effect proline uptake. Careful closure of the sheath with restoration of a synovial environment does not appear to be necessary for tendon nutrition.     

Operative findings in camptodactyly of the little finger.

In five of six cases of camptodactyly in which an abnormality of the flexor tendon was examined at operation, the flexor digitorum superficialis tendon was hypoplastic and there was no continuity of the normal tendon between the muscle belly and bony insertion. The proximal end of the flexor digitorum superficialis tendon was attached to the palmar aponeurosis and the flexor tendon sheath of the ring finger in two patients, to the palmar aponeurosis in one, to the undersurface of the transverse carpal ligament in one and to the flexor tendon sheath of the ring finger in one. The tenodesis effect of the abnormal tendon of the flexor digitorum superficialis is considered to play an important role in the cause and rapid increase of the deformity of camptodactyly.     

Fibroma of the flexor hallucis longus tendon sheath

Fibroma of tendon sheath is a rare benign tumor that usually occurs in upper extremities. It is mostly asymptomatic and grows slowly within the tendons or tendon sheaths. Histopathologic findings show well-demarcated nodules consisting of haphazardly arranged fibroblast-like spindle cells, which are embedded in a dense, collagenous matrix. We present a patient with fibroma of the tendon sheath on the flexor hallucis longus tendon, which was in an unusual location and has never been reported. The lesion was completely excised and showed no evidence of recurrence after 2 years of follow-up.     

Trigger Wrist

Trigger wrist is a relatively rare disease compared to trigger finger, which is the most common disorder found in hands. Patients with trigger wrist usually complain about the following symptoms: snapping and clicking or triggering around carpal tunnel with or without mild to moderate median neuropathy. There are a total of five cases of trigger wrist: three cases of anomalous muscle belly of flexor digitorum superficialis and two cases of fibroma around flexor tendon sheath within carpal tunnel. This study reports on two of those cases: one with anomalous muscle and the other with fibroma of flexor tendon sheath. Accurate examination and proper diagnosis are mandatory to obviate improper and time-wasting treatment for patients with trigger wrist.     

The Vascularization and Structure of the Human Digital Tendon Sheath as Related to Flexor Tendon Function: An Angiographic and Histological Study

The gliding surfaces of the flexor tendons and the tendon sheath are delicate structures of the complex digital flexor system. Beside the fibrous parts, the tendon sheath also exhibits membranous synovial components, which represent a dialysing membrane producing a plasma ultrafiltrate—the synovial fluid. In this study, interest was focused on the vascularization of the synovial sheath. By a microangiographic method it was demonstrated that this membrane is richly vascularized and that the vascular plexus is in continuity on the outside of the fibrous pulleys. The friction surfaces of the system—the inside of the pulleys and the surface of the flexor tendons—are devoid of vessels, and here a differentiation into chondrocyte-like cells is observed. It is suggested that these tissue areas, in analogy to joint cartilage, are nourished by diffusion from the synovial fluid, and that the flexor system can be regarded as a specialized joint, sliding longitudinally and exhibiting an extremely large range of motion.     

同种异体有滑膜肌腱手部鞘内移植的临床应用

目的:根据屈指肌腱的应用解剖和屈指肌腱鞘内移植的实验研究结果,本文介绍用异体有滑膜肌腱进行鞘内移植的临床应用报道。方法:用异体有滑膜肌腱修复指腱鞘内肌腱缺损18例,26条肌腱。随访7月～78年,平均58年,功能测定(TAM法),优良率72%,可11%,差17%。未见明显排斥反应。结论:经肌腱保存液处理后的同种异体有滑膜肌腱替代自体鞘内肌腱移植可以取得比较满意的临床效果。