1. A CLINICAL PRESENTATION ON SUPPURATIVE TENOSYNOVITIS AREA- ORTHOPEDIC WARD IN WESTERN REGIONAL HOSPITAL ,POKHARA BY- MR YOGENDRA PD. MEHTA MN IN ADULT NURSING YEAR-FIRST BATCH- SECOND 1

2. HEALTH HISTORY DEMOGRAPHIC DATA Name : Mr. Santa Bdr. Rana Age/Sex: 65 Years/ Male Address: Syangja,Putalibazar-1 Marital Status: Married No. of Children: 9 (Male-4; Female-5) Religion: Baudha Ethnicity : Magar Types of Family: Nuclear Education: Literate (up to 6 class) Occupation: Retired Nepal Army & Boxer Informant: Self 2 3. Contd 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 3 4. CHIEF COMPLAINTS 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. 4 5. 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. 5 6. Contd. 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 management. 6 7. 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 etc. Surgical history: None Hospitalizations: No history of previous hospitalization Injuries and accidents: Many years back h/o Fall Injury 7 8. PERSONAL HISTORY Alcohol: He was alcoholic and Left alcohol drinking since 9 years. 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 8 9. DRUG HISTORY Not Any Significant history towards the drug. Not any drug allergic reaction. Taking Oral Hypoglycemic agent- Metformin, Glimepiride 9 10. FAMILY HISTORY S.NO NAME SEX AGE EDUCATION MARITAL STATUS HEALTH STATUS 1 Shyam Rana Male 36 Yrs 10+2( Suadi Arab) Married Healthy 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 7 Shreejana Rana Female 24 Yrs 10+2 Married Healthy 8 Radhika Rana Female 22 Yrs 10+2 Married Healthy 9 Jivan Rana Male 20 yrs SLC Unmarried Disabbled( Hearing Loss & Limping Leg) 10 11. 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 11 12. PHYSICAL EXAMINATION Patient was conscious and afebrile. General Examination Date-2069/06/15 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 13. Contd 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 13 14. Contd Neck: Not Any deformity, Thyroid: Not palpable Clavicular LN: Not palpable Chest: O/I -Symmetrical, B/L equal Movement of chest,Not any scar present 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 14 15. Contd Axillary: B/L axillary LN- Not palpable Abdomen: 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) Bowel/Bladder: No constipation, Normal bowel 2 times a day and normal urination, No bladder full 15 16. Contd. 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 Muscles Strength: Normal- 5/5 (graps tightly to any object) Muscles Tone: Normal(No flaccid, soft) Temperature: Normal 16 17. Contd.. Tendenic Reflexes: Elbow- Normal, Wrist- Normal Lt. Upper extremities: -Deformity seen at thumb and wrist joint movement restricted -Pain at Extension ofThumb and wrist joint movement -Swelling, Redness & tender of the dorsum part and volar surface of left hand -partial flexion fingers, extension &circumduction movement of wrist and affected phalenges. Muscles Strength: 4/5(Not able to graps tightly to any object due to pain) Muscles Tone: Normal Tendenic reflexes: Elbow-Normal, Wrist- Decreased 17 18. Contd. Touch: B/L Normal Sensation: Tingling , Numbness present in left affected part Temperature: Increased at left affected part Lower Extremities: -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 18 19. 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 weakness, - Affected area may show redness (erythema), edema, and warmth to the touch. 19 20. Contd Laboratory Tests: Laboratory tests are not necessary for diagnosis. Tests for suspected infectious tenosynovitis may include: - 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. Radiology: - 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 21. DIAGNOSTIC APPROACH DONE ON PATIENT Date: 2069/06/14 21 S.NO TEST DONE OBTAINED READING NORMAL READING 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 Incubation 22. FINAL DIAGNOSIS On the basis of history, examination, clinical features & X-Ray finding Mr. Shanta Bdr Rana was diagnosed as Suppurative TenoSynovitis 22 23. SUPPURATIVE TENOSYNOVITIS INTRODUCTION 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 any joint. 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. 23 24. ANATOMY 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 sheath. Infectious tenosynovitis involving the flexor tendons on the dorsum of the hand can spread via bursae to the volar surface of the hand Infectious tenosynovitis involving the tendon sheaths of the wrist can spread to adjacent bursae and tendon sheaths surrounding the ulna and radius 24 25. Contd 25 Flexor tendon sheaths and radial and ulnar bursae 26. Contd.. Epidemiology -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. Recent Studies: - 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 pathogen(Staphylococcus). 26 27. BACTERIAL ETIOLOGY S.N ACCT. to INTERNET EVIDENCE IN MY PATIENT Remark 1 Neisseria gonorrhea Not Present 2 Staphylococcus 3 Streptococcus 4 Pasteurella multocida (cat bites), 5 Eikenella corrodens (human bites) 27 28. RISK FACTOR 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 and Boxer 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 28 29. PATHOPHYSIOLOGY Trauma, DM , Infection cause Risk for growth of microbes in Between the space of Parietal & Visceral layer of Tendon lead to Increased Synovial fluid & Development of Microbes As a result Compromise of surrounding Blood Vessels & Nerve( Median nerve) Lead to Tissues, Bone & Tendon necrotized result to Inflammation of Flexor tendon & Synovial Sheath Present with Pus Formation, Swelling, Crepitus Sound, Decreased ROM, reddened, Increased local Temperature 29 30. CLINICAL FEATURES S.N ACC. To INTERNET EVIDENCE IN PATIENT REMARK 1 Insedious swelling of dorsum part of limb Sudden swelling of dorsum part of lt hand at volar surface 2 Pain, Tenderness, Rednened at the affected part Present 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 sheath, Present at thumb n middle finger 7 pain with passive extension of the digit. Pain at thumb & wrist joint at extension 8 Pus with Fever No Fever but pus was present 9 Decreased ROM of wrist joint present 30 31. TREATMENT ACC. TO INTERNET EVIDENCE Non Surgical Approach: Individuals are often advised to wear a splint temporarily to avoid recurrence. 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 inflammation. 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 helpful. Surgical Approach: Release of tendon sheath I& D 31 32. TREATMENT DONE IN PATIENT Non Surgical Approach: Date: 2069/06/14 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 32 33. ASSESSMENT & INVESTIGATION DONE IN PATIENT BEFORE SURGICAL APPROACH Date: 2069/06/16 Blood Sugar: - Fasting:100mg/dl - PP:170mg/dl - Random:125mg/dl ( Normal-80-140mg/dl) ASSESSMENT 33 S.N PARAMETER AFFECTED LT. HAND 2069/06/14 2069/06/17 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 34. Contd.. Surgical Approach: Date: 2069/06/18 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 4 days. Tissue sample was sent for Histopathology test in lab. 34 35. Contd Date:2069/06/19 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 35 36. NURSING INTERVENTION DONE DURING HOSPITAL STAY 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 care. 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 adhesive tape. IV site swelling part was care with sprit bandaging. Pre & Post operative care was done. 36 37. DISCHARGE OF PATIENT ASSESSMENT Date: 2069/06/22 37 S.NO PARAMETERS FINDING 1 Inflammation(Pain, Tender , Redness, Local temperature) Absent 2 ROM, Movement of digit Well, Normal 3 Swelling Decreased 4 Wound Dry, No pus, Granulation tissue present 38. Contd ASSESSMENT Date: 2069/06/22 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 report. Tab Fluclox 500mg x PO x QID for 7 days Tab flexion 1 tab x TDS for 3 days 38 39. DISCHARGE TEACHING TO THE PATIENT & FAMILY 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 ordered. 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 histopathology report. Patient and family was informed about the hypoglycemic features and management. 39 40. PROGNOSIS According to Internet evidence- If treatment is delayed after diagnosis for long time, outcomes will be worse. Presence of septic pathogens(Staphylococcus aureus) result worse outcome. 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 Infective tenosynovitis. 40 41. COMPLICATION Complications of Suppurative Tenosynovitis include: Chronic pain of affected part. Permanent decreased of ROM. Rupture of Tendon Septic Arthritis Osteomyelitis Amputation 41 42. REFERENCES 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. 2009 http://emedicine.medscape.com/article/809777-overviev. Chen, Andrew L. "Tenosynovitis." MedlinePlus. 17 Nov. 2008. National Library of Medicine. 13 Mar. 2009 http://www.nlm.nih.gov/medlineplus/ency/article/001242.htm. 42 43. 43 THANK YOU