Manual of Surgery Volume First: General Surgery. Sixth Edition.

by Alexis Thomson; Alexander Miles

Suppurative Teno-synovitis.—This form usually follows upon infected wounds of the fingers—especially of the thumb or little finger—and is a frequent sequel to whitlow; it may also follow amputation of a finger. Once the infection has gained access to the sheath, it tends to spread, and may reach the palm or even the forearm, being then associated with cellulitis. In moderately acute cases the tendon and its sheath become covered with granulations, which subsequently lead to the formation of adhesions; while in more acute cases the tendon sloughs. The pus may burst into the cellular tissue outside the sheath, and the suppuration is liable to spread to neighbouring sheaths or to adjacent bones or joints—for example, those of the wrist.

The treatment consists in inducing hyperæmia and making small incisions for the escape of pus. The site of incision is determined by the point of greatest tenderness on pressure. After the inflammation has subsided, active and passive movements are employed to prevent the formation of adhesions between the tendon and its sheath. If the tendon sloughs, the dead portion should be cut away, as its separation is extremely slow and is attended with prolonged suppuration.

Gonorrhœal Teno-synovitis.—This is met with especially in the tendon sheaths about the wrist and ankle. It may occur in a mild form, with pain, impairment of movement, and œdema, and sometimes an elongated, fluctuating swelling, the result of serous effusion into the sheath. This condition may alternate with a gonorrhœal affection of one of the larger joints. It may subside under rest and soothing applications, but is liable to relapse. In the more severe variety the skin is red, and the swelling partakes of the characters of a phlegmon with threatening suppuration; it may result in crippling from adhesions. Even if pus forms in the sheath, the tendon rarely sloughs. The treatment consists in inducing hyperæmia by Bier's method; and a vaccine may be employed with satisfactory results.

Tuberculous Disease of Tendon Sheaths.—This is a comparatively common affection, and is analogous to tuberculous disease of the synovial membrane of joints. It may originate in the sheath, or may spread to it from an adjacent bone.

The commonest form—hydrops—is that in which the synovial sheath is distended with a viscous fluid, and the fibrinous material on the free surface becomes detached and is moulded into melon-seed bodies by the movement of the tendon. The sheath itself is thickened by the growth of tuberculous granulation tissue. The bodies are smooth and of a dull-white colour, and vary greatly in size and shape. There may be an overgrowth of the fatty fringes of the synovial sheath, a condition described as “arborescent lipoma.”

The clinical features vary with the tendon sheath affected. In the common flexor sheath of the hand an hour-glass-shaped swelling is formed, bulging above and below the transverse carpal (anterior annular) ligament—formerly known as compound palmar ganglion. There is little or no pain, but the fingers tend to be stiff and weak, and to become flexed. On palpation, it is usually possible to displace the contents of the sheath from one compartment to the other, and this may yield fluctuation, and, what is more characteristic, a peculiar soft crepitant sensation from the movement of the melon-seed bodies. In the sheath of the peronei or other tendons about the ankle, the swelling is sausage-shaped, and is constricted opposite the annular ligament.

The onset and progress of the affection are most insidious, and the condition may remain stationary for long periods. It is aggravated by use or strain of the tendons involved. In exceptional cases the skin is thinned and gives way, resulting in the formation of a sinus.

Treatment.—In the common flexor sheath of the palm, an attempt may be made to cure the condition by removing the contents through a small incision and filling the cavity with iodoform glycerine, followed by the use of Bier's bandage. If this fails, the distended sheath is laid open, the contents removed, the wall scraped, and the wound closed.

A less common form of tuberculous disease is that in which the sheath becomes the seat of a diffuse tuberculous thickening, not unlike the white swelling met with in joints, and with a similar tendency to caseation. A painless swelling of an elastic character forms in relation to the tendon sheath. It is hour-glass-shaped in the common flexor sheath of the palm, elongated or sausage-shaped in the extensors of the wrist and in the tendons at the ankle. The tuberculous granulation tissue is liable to break down and lead to the formation of a cold abscess and sinuses, and in our experience is often associated with disease in an adjacent bone or joint. In the peronei tendons, for example, it may result from disease of the fibula or of the ankle-joint.

When conservative measures fail, excision of the affected sheath should be performed; the whole of the diseased area being exposed by free incision of the overlying soft parts, the sheath is carefully isolated from the surrounding tissues and is cut across above and below. Any tuberculous tissue on the tendon itself is removed with a sharp spoon. Associated bone or joint lesions are dealt with at the same time. In the after-treatment the functions of the tendons must be preserved by voluntary and passive movements.