Reason: Eval for extent of tenosynovitis; s/p L hand debridement History: Same There is full thickness rupture of the flexor tendon apparatus of the index finger. The distal end of what we believe to be the superficial flexor tendon lies at the level of the second metacarpal neck. What we suspect is the torn proximal end of the deep flexor tendon appears to lie at the level of the distal radial diaphysis. The torn end of the distal tendon fragment is seen at the level of the proximal phalanx. Within the palm, between the torn tendon fragments, is a rim enhancing collection of fluid that appears to penetrate the volar skin surface. There is enhancement along the flexor tendon apparatus of the index finger, both proximal and distal to this fluid collection, indicating tenosynovitis, extending proximally into the carpal tunnel. From the carpal tunnel, enhancement extends distally along the entire flexor pollicis longus tendon, the entire flexor tendon apparatus of the middle finger, and to a lesser degree along the flexor tendons of the ring and fifth fingers, indicating tenosynovitis. There are multiple foci of signal void within the palmar soft tissues, extending into the index finger and also noted within the ring finger, which could represent foci of gas or metallic foreign bodies. The inflammation extends from the carpal tunnel into the anterior compartment of the forearm. There is a fluid collection in the mid forearm between the superficial and deep finger flexors, measuring just over 1cm in transverse dimension and approximately 3cm in longitudinal dimension, that likely represents an abscess. There is also intramuscular and intermuscular edema and enhancement of the volar compartment of the forearm, suggesting inflammation. However, there is edema within one of the forearm flexor muscles that we suspect is the flexor carpi radialis, with its tendon appearing to be disrupted at the level of the distal forearm. Once again, there are foci of signal void within the volar and radial soft tissues of the forearm that may reflect metallic foreign bodies or gas. There is also enhancement along the extensor tendons extending into the fingers (particularly the index, middle and ring fingers) indicating additional tenosynovitis with extension of inflammation proximally into the forearm. Although we see no focal fluid collections within the posterior compartment of the forearm, there is a small fluid collection within the subcutaneous tissues of the hand dorsal to the base of the third metacarpal, measuring approximately 1cm in diameter. There is also a subcentimeter fluid collection in the subcutaneous fat of the dorsomedial wrist. Once again, there are several foci of signal void within the dorsal soft tissues of the hand, wrist and forearm which may reflect metallic debris or gas. There is diffuse edema of much of the subcutaneous fat of the forearm. There is enhancement of the subcutaneous fat dorsal to the olecranon, extending distally through the medial subcutaneous fat of the forearm, compatible with cellulitis. There is diffuse synovitis of the wrist with carpal bone edema and erosions, indicating an inflammatory, likely infectious, arthritis.
Extensive inflammatory changes of the hand, wrist and forearm as described above, including extensive tenosynovitis, inflammatory (probably septic) arthritis of the wrist, and tendon ruptures as described above. Furthermore, there are multiple foci of signal void within the soft tissues of the hand, wrist and forearm, but we cannot determine whether these represent small metal fragments or foci of gas. This could be further evaluated with radiographs. Findings were discussed by telephone with Dr. Foertsch of the Plastic Surgery service (at pager 4739) on 11/1/2016 10:09 AM.