A clinical presentation on supporative tenosynovitis in Orthoprdic ward of WRH, Pokhara Done by Mr Yogendra Mehta, MN in Adult Nursing, Second Year, Institute of Medicine, Pokhara Campus, Pokhara
A CLINICAL PRESENTATION ON SUPPURATIVE
AREA- ORTHOPEDIC WARD IN WESTERN
REGIONAL HOSPITAL ,POKHARA
BY- MR YOGENDRA PD. MEHTA
MN IN ADULT NURSING
Name : Mr. Santa Bdr. Rana
Age/Sex: 65 Years/ Male
Marital Status: Married
No. of Children: 9 (Male-4; Female-5)
Ethnicity : Magar
Types of Family: Nuclear
Education: Literate (up to 6 class)
Occupation: Retired Nepal Army & Boxer
IP.No. : 1193999
Bed no. : 15
Department : Orthopedic
Blood group: B +ve
Final Diagnosis: Suppurative TenoSynovitis
Doctor incharge: Dr. Yagya man Shakya
Date of admission: 2069-06-14
Date of Discharge: 2069/06/22
Total stay of Hospital: 8 days
H/o fall injury many years back
Patient C/o- swelling for 11 days with pain of dorsal surface of
palm and wrist joint of lt. hand.
Difficult to move wrist joint since 11 days.
H/o tenderness but no fever.
Tingling and numbness for 5 days.
Crepitus present on movement on affected site.
HISTORY OF PRESENT ILNESS
Patient was fine and doing his normal work 11 days back. He
had swelling at the wrist joint and dorsum surface of palm over
the volar surface of left hand suddenly. He has pain over the
swelling area and not able to move his wrist joint. He went to
the local medical clinic and their he treated with analgesic on
2069/06/05 and asked him to consult senior doctor. He took the
medicine tab Brufen 400mg x BD ; Tab Nimuslide 100mg x BD.
But he did not get relief of pain and swelling.
Finally, he attained to the Ortho OPD of WRH, Pokhara on
2069/06/14. On Examination, Doctor suspected a pus
collection at the swelling area and they aspirate the pus
with purulent color with fowl smell and send to the
laboratory for the culture and sensitivity test. Then he was
diagnosed Infective TenoSynovistis & admitted to the Ortho
ward on Bed no.15 for the further Investigation and
HISTORY OF PAST ILLNESS
• Medical history: Known case of Diabetes Mellitus since 1 year
and he is under Treatment with:
- Cap Metformin 1000mg x po x OD
- Tab Glimepiride 1ng x OD in morning
- Tab Ramipril 2.5 mg x OD xHS
• Not any past history of pulmonary tuberculosis, Asthma, malaria
• Surgical history: None
• Hospitalizations: No history of previous hospitalization
• Injuries and accidents: Many years back h/o Fall Injury
• Alcohol: He was alcoholic and Left alcohol drinking since 9
• Smoking: He was chain smoker and left since 26 year.
• Veg/Non-Veg: Non Vegetarians.
• Appetite: Normal
• Sleeping pattern: Normal without Snoring
• Bowel/Bladder: Normal
• Sports: He played Boxing previously
• Not Any Significant history towards the drug.
• Not any drug allergic reaction.
• Taking Oral Hypoglycemic agent- Metformin, Glimepiride
SEX AGE EDUCATION MARITAL
1 Shyam Rana Male 36 Yrs 10+2( Suadi
2 Budhi Rana Male 34 Yrs SLC ( Saudi Arab) Unmaried Healthy
3 Arati Rana Female 30 Yrs Master degree Married Healthy
4 Shova rana Female 27 Yrs Master Degree Married Healthy
5 Rajesh Rana Male 25 Yrs SLC(Nepal Army) Unmarried Healthy
6 Jyoti Rana Female 26 Yrs Bachelor Healthy
Female 24 Yrs 10+2 Married Healthy
Female 22 Yrs 10+2 Married Healthy
9 Jivan Rana Male 20 yrs SLC Unmarried Disabbled(
Hearing Loss &
FAMILY HEALTH HISTORY
In Mother :
• High blood pressure : no
• Diabetes : no
• Any other significant disease: Not any Significant
diseases like HTN, TB, DM, Allergic Rxn
In Father :
• High blood pressure : no
• Diabetes : yes
• Any other disease : not any significant disease like
TB, HTN, Allergic reaction
Patient was conscious and afebrile.
• Anthropometric Assessment:
• Weight: 60kg
• Height: 5.5
• Vital Signs:
• Blood Pressure- 130/80 mm of Hg
• Pulse- 78/min
• Respiratory Rate- 22/min
• Temperature- 98F 12
• Head: No Scar, No Pediculosis, No Dandruff present
Hair soft, black and white in color
• Eye: Normal position, No discharge
Vision-Rt- 6/6 ; Lt- 6/6,
No Pallor, Icterus
• Ear: Not any significant deformities, no presence of wax, no
discharge, no hearing loss
• Nose: Not any Significant change and deformities,No discharge
and blockage of both nares.
• Mouth: No cracking of lips, Normal lips, Absence of
Halitosis, Complete denture, No dental carries
• Neck: Not Any deformity,
Thyroid: Not palpable
Clavicular LN: Not palpable
O/I -Symmetrical, B/L equal Movement of chest,Not any scar
O/P –No tenderness, No mass palpable over the chest
O/A- Lungs: B/L equal entry of air, vesicular sound
Heart: S1 and S2 sound normal
• Axillary: B/L axillary LN- Not palpable
O/I: Normal, Oval , No scar seen
O/P:Soft, No tenderness, No guarding & rigidity, No mass
palpable, No liver and spleen palpable
O/A: Normal Bowel sound present
(5 times in one 1min)
-Abdominal Reflex: Normal( Contract in every quadrant
& umbilicus move towards the stimulated site)
No constipation, Normal bowel 2 times a day and normal
urination, No bladder full
• Upper extremities:
Rt. Upper Limb-
-Not any deformity seen, normal acromium, elbow, phalengial and
wrist joint movement,
-No pain at joint movement,
-Presence of IV cannula at the radial aspect of hand,
-Swelling, tender at the IV infusion site
-Presence of flexion, extension & circumduction movement of wrist
Normal- 5/5 (graps tightly to any object)
Muscles Tone: Normal(No flaccid, soft)
• Tendenic Reflexes:
Elbow- Normal, Wrist- Normal
Lt. Upper extremities:
-Deformity seen at thumb and wrist joint
-Pain at Extension ofThumb and wrist joint
-Swelling, Redness & tender of the dorsum part
and volar surface of left hand
-partial flexion fingers, extension
&circumduction movement of wrist and
4/5(Not able to graps tightly to any object due to
Muscles Tone: Normal
Elbow-Normal, Wrist- Decreased
• Touch: B/L Normal
• Sensation: Tingling , Numbness present in left affected part
• Temperature: Increased at left affected part
-B/L Normal movement of joint
-No pain, swelling, and deformities
-Muscles power: B/L normal
-Tendenic reflexes: Knee joint reflexes(++), Ankle joint Reflexes(++)
and planter reflexes-Normal(flexion of foot)
• Touch: B/L Normal
• Sensation: No Tingling , Numbness present
• Temperature: Normal
DIAGNOSTIC APPROACH Acct. To BOOK
Physical Examination reveals
- Kanaval signs of flexor tendon sheath infection which are:
(1) finger held in slight flexion,
(2) fusiform swelling,
(3) tenderness along the flexor tendon sheath
(4) pain with passive extension of the digit.
- Decrease Range of motion.
- In particularly painful cases, the involved joint may exhibit
- Affected area may show redness (erythema), edema, and warmth
to the touch.
Laboratory Tests: Laboratory tests are not necessary for
diagnosis. Tests for suspected infectious tenosynovitis may
- Complete blood count (CBC)
- Erythrocyte sedimentation rate (ESR)
- Pus cultures.
- In some cases, fluid may be withdrawn from a swollen joint for
further diagnostic evaluation.
- X-Ray are sometimes taken to rule out other pathology or to look
for tendon calcifications. Although not usually necessary.
H/O Trauma, Injury 20
DIAGNOSTIC APPROACH DONE ON PATIENT
• Date: 2069/06/14
S.NO TEST DONE OBTAINED READING NORMAL
1 Blood Sugar(R) 173mg/dl 80-140
2 WBCs 10800/mm3
3 Neutrophil 83%
4 Lymphocytes 14%
5 Eosinophil 02%
6 Monocytes 01%
7 ESR Not Done
8 X-Ray of Hand Done &Thick Tendon,Bone
9 Pus Culture No growth after 2 days of
On the basis of
history, examination, clinical
features & X-Ray finding Mr.
Shanta Bdr Rana was diagnosed as
• Tenosynovitis refer to inflammation or infection of flexor tendon
and synovial sheath.
• It is a pathophysiologic state causing disruption of normal
flexor tendon function in the hand.
• It occurs most frequently in the hands and wrist but can occur in
• Tenosynovitis develops when the inner (synovial) lining of the
tendon sheath becomes injured or inflamed.
• Pyogenic flexor tenosynovitis (FT) results from an infectious agent
multiplying in the closed space of the flexor tendon sheath and
culture-rich synovial fluid medium.
• The anatomic placement of tendons, their sheaths and the
adjacent bursae has important implications for the clinical features
of tenosynovitis (inflammation of a tendon sheath)
• Extensor and flexor tendon sheaths have two surfaces: an inner
visceral layer adherent to the tendon and an outer parietal layer
abutting adjacent structures such as bursae and muscles.
• The visceral and parietal layers of most tendons are tightly joined
at the ends to produce a closed compartment encased in a tendon
• Infectious tenosynovitis involving the flexor tendons on the
dorsum of the hand can spread via bursae to the volar surface of
• Infectious tenosynovitis involving the tendon sheaths of the wrist
can spread to adjacent bursae and tendon sheaths surrounding
the ulna and radius 24
Flexor tendon sheaths and radial and ulnar bursae
-An estimated 64-95% of patients with rheumatoid arthritis develop hand or wrist FT.
-One third of hand and finger FT cases are associated with diabetes mellitus.
- According to Eshed et al , flexor tenosynovitis which is diagnosed by MRI is
strongly predictor of early rheumatic arthritis.
- According to Kameyama et al, limited joint mobility in patient with DM is closely
related to stenosing flexor tenosynovitis.
- His studies also shows that diabetic patient have significant prevalence of multiple
digit involved in flexor tenosynovitis.
- According to Dailiana et al retrospective study among 41 patient with purulent
tenosynovitis, found the best functional outcomes with early diagnosis and
treatment with I & D.
- Worse outcomes resulted in case of delayed treatment and infection with septic
S.N ACCT. to INTERNET EVIDENCE IN MY PATIENT Remark
1 Neisseria gonorrhea
4 Pasteurella multocida (cat bites),
5 Eikenella corrodens (human bites)
S.N ACCT. to INTERNET EVIDENCE IN MY PATIENT Remark
1 Carpenters, Painters, Welder Not any
2 Swimmers Not Applicable
3 Sports: Base Ball player, Tennis player
He is Boxer
4 Diabetes Mellitus He is Diabetic
5 Pregnancy Not Applicable
6 Injury, Trauma Presence h/o Injury
7 High Pressure Injection wound Not any Oil or grease injection
Trauma, DM , Infection
Risk for growth of microbes
Between the space of Parietal & Visceral layer of Tendon
Increased Synovial fluid & Development of Microbes
As a result
Compromise of surrounding Blood Vessels & Nerve( Median nerve)
Tissues, Bone & Tendon necrotized
Inflammation of Flexor tendon & Synovial Sheath
Pus Formation, Swelling, Crepitus Sound, Decreased ROM, reddened, Increased local
S.N ACC. To INTERNET EVIDENCE IN PATIENT REMARK
1 Insedious swelling of dorsum part
Sudden swelling of dorsum part
of lt hand at volar surface
2 Pain, Tenderness, Rednened at the
3 Restricted movement of finger Present
4 Finger held in slight flexion Present
5 Finger is Uniform swelling Present
6 Tenderness along the flexor tendon
Present at thumb n middle
7 pain with passive extension of the
Pain at thumb & wrist joint at
8 Pus with Fever No Fever but pus was present
9 Decreased ROM of wrist joint present 30
TREATMENT ACC. TO INTERNET EVIDENCE
Non Surgical Approach:
• Individuals are often advised to wear a splint temporarily to avoid
• Nonsurgical (conservative) treatment for tenosynovitis may utilize
Ultrasound Iontophoresis, and electrical stimulation.
• Apply heat or ice for local pain control and to reduce swelling and
• Oral non-steroidal anti-inflammatory drugs (NSAIDs) may be
prescribed to control mild to moderate pain.
• In some cases, injection of lidocaine or a corticosteroid may be
• Release of tendon sheath
• I& D
TREATMENT DONE IN PATIENT
Non Surgical Approach:
• Cap metformin 1000mgx pox OD
• Tab Glimepiride 1ng x OD morning time
• Tab Ramipril 2.5 mg x HS
• Inj. Flucloxacillin 500mg xIV x QID
• Inj. Ketral 1amp x IV x BD
• Inj. Aciloc 50mg X IV x BD
ASSESSMENT & INVESTIGATION DONE IN
PATIENT BEFORE SURGICAL APPROACH
• Blood Sugar:
- Random:125mg/dl ( Normal-80-140mg/dl)
S.N PARAMETER AFFECTED LT. HAND
1 Local Temperature Increased Decreased
2 Redness Increased Decreased
3 Pain Severe Mild
4 Tenderness Severe Moderate
5 Swelling ++++ ++
6 ROM(wrist & Thumb) decreased Improved
• Surgical approach done after 4 days
due to decrease inflammation.
• I & D was done to my patient under
IVA( Intravenous Anesthesia).
• 10 ml pus was drained.
• They continue same medicine for more
• Tissue sample was sent for
Histopathology test in lab. 34
• All the injectable medicines were changed into the oral form.
- Tab Fluclox 500mg x PO x QID
- Tab Nims 100mg x PO x BD
- Cap Omez 20mg x PO x BD
- Tab T.T Dox 100mg x PO x OD
- Tab Azithro 500mg x PO x OD
NURSING INTERVENTION DONE DURING
Vital sign was monitored as ward policy.
Medication was given as ortho surgeon & physician ordered.
Dressing of the wound was done in alternate day with betadine &
normal saline under aseptic technique.
Diabetic diet was advised to patient for intake.
Advised for daily exercise and education for the digitorium & foot
Psychological support was given to the patient by informing him
about the disease condition and its treatment and prognosis.
IV site care was done daily with sprit swab and changing of
IV site swelling part was care with sprit bandaging.
Pre & Post operative care was done. 36
DISCHARGE OF PATIENT
S.NO PARAMETERS FINDING
1 Inflammation(Pain, Tender , Redness, Local
2 ROM, Movement of digit Well, Normal
3 Swelling Decreased
4 Wound Dry, No pus, Granulation tissue present
Mr Shanta Bdr. Rana was
discharged on 2069/06/22 under
following medicines and advised
for follow up to the ortho OPD after
2 weeks with Histopathology
• Tab Fluclox 500mg x PO x QID for 7
• Tab flexion 1 tab x TDS for 3 days
DISCHARGE TEACHING TO THE PATIENT &
Patient and Family was informed about the prognosis of disease.
Advised for alternate wound dressing in near health centre.
Advised patient to maintain good personal hygiene.
Advised patient for the timely medicine intake for full course as
Asked patient to perform daily exercise.
patient was educated for foot care and diabetic diet.
Asked patient and family to attain ortho OPD after 2weeks with
Patient and family was informed about the hypoglycemic features
According to Internet evidence-
• If treatment is delayed after diagnosis for long time, outcomes will
• Presence of septic pathogens(Staphylococcus aureus) result worse
Prognosis in my Patient:
• Treatment started immediately after diagnosis.
• No presence of any septic pathogens.
As above evidence chance of prognosis is good for recovery from
Complications of Suppurative Tenosynovitis include:
• Chronic pain of affected part.
• Permanent decreased of ROM.
• Rupture of Tendon
• Septic Arthritis
• Elsevier, Inc. "Flexor Tendon Sheath Infection." Patient Education.
MD Consult. 13 Mar. 2009 http://home.mdconsult.com.
• Norvell, Jeffrey G., and Mark Steele. "Tenosynovitis." eMedicine.
Eds. Richard S. Krause, et al. 31 Mar. 2008. Medscape. 13 Mar.
• Chen, Andrew L. "Tenosynovitis." MedlinePlus. 17 Nov. 2008.
National Library of Medicine. 13 Mar. 2009