Tenosynovitis in drug addicts

Five patients with identical history, physical findings, and laboratory data were diagnosed as having teno.\ynol'itis following inadl'ertent infiltration of drugs into the extensor tendon sheaths of their hands. The differential diagnosis r1{ rheumatoid, tubercular, and other inflammatory reaction of bacterial origin was ruled out. Detailed microscopic examination re\'ealed the presence of birefringent carbohydrate particles along the synovial sheaths confirming the diagnosis in these patients. Appropriate operative procedures, synovectomy, and lor partial tendon resection and anastomoses were succes.~fully perj(~rmed for all patients.

Avtar S. Dhaliwal, M.D., F.A.C.S., and Arthur L. Garnes, M.D., F.A.C.S., Johnson City, Tenn.

Drug abuse in the United States is approaching epidemic proportions at all social and economic levels. There have been numerous articles in the literature per­taining to the medical and surgical complications result­ing from this habit. 1-

9 Relative to the upper extremity, the common manifestations of heroin addiction include skin tracks, thrombophlebitis, puffy hands, pop scars, cellulitis, abscesses and ulcers on the dorsum of the hand and fingers. As the veins of the antecubital area and forearm become obliterated, the venous plexus on the dorsum of the hand is commonly used for "mainlin­ing,'' the injection of the drug directly into the vein.

Heroin is the drug of choice of most addicts because of the euphoria it causes and its minimal side effects. 4 It is not sold in its •'pure'' form but is cut or diluted before reaching the consumer. Various fillers or stretchers are used, the most commonly used being Quinine, sugar, lactose, and baking soda. Quinine has long been recognized as a caustic tissue irritant. 2

In searching for patent veins on the dorsum of the hand, the addict may inject the drug directly into the synovial sheaths of the extensor tendons. The result is a chronic proliferative inflammatory reaction of the in­vesting tendon sheaths and possible compromise of tendon nutrition. The clinical picture can be easily con­fused with rheumatoid tenosynovitis. A few case re­ports of suppurative tenosynovitis 7 on the palmar aspect of fingers have been recorded, but granulomatous tenosynovitis of the extensor tendons has not been re­ported. This article reports on five patients diagnosed as

From the Department of Plastic Surgery, East Tennessee State Uni­versity Medical School, Johnson City, Tenn.

Received for publication June 8, 1981.

Reprint requests: Avtar S. Dhaliwal, M.D., North Side Professional Bldg., 403 Princeton Rd., Johnson City, TN 37601.

Fig. 1. Swelling on dorsum of hand. Tense, cystic, nonten­der, and moving with contraction of extensor tendons.

Table I. Historical data

Pa- Admission Duration of tient's of addiction Dominated Involved

age Sex injection (years) hand hand

29 F + 8 Right Right 42 M + 15 Right Right 48 M + 13 Right Right 36 M + 17 Right Left 45 M + 19 Right Right

Table II. Signs of tenosynovitis in drug addicts

Swelling on dor- Ruptured ex-sum of hand tensor tendons

+ + + + Index and mid-die fingers

+ + + + Fifth finger + + + + + +

626 THE JOURNAL OF HAND SURGERY 0363-5023/82/060626+03$00.30/0 © 1982 American Society for Surgery of the Hand

Vol. 7, No.6 November 1982 Tenosynm·itis in drug addicts 627

Fig. 2. At surgery. Lobulated appearance of swellings pro­ Fig. 3. Degenerated and frayed extensor tendons. duced by compression of extensor retinaculum.

Table III. Laboratory data for tenosynovitis in drug addicts

X-ray bones Culture synovial White blood count IUric acid mg% I IFixation synovial IC-reactive I (X /03) (NL 2.5 - 8) Latex serum fluid

10.1 1.8 9.2 2.7 6.5 6.5 7.4 3.2 5.5 5.3

having tenosynovitis of the extensor surface of their hands secondary to injection of drugs into the synovial sheaths.

Clinical picture

The salient points in clinical history of these patients are shown in Table I. The patients gave a history of heroin addiction resulting from intravenous injections over periods ranging from 8 to 19 years. The dominant right hand was involved in four out of five patients, implying that the nondominant, less skilled, left hand was used to inject the drug into the veins-thus increas­ing the chances of missing the vein and entering the synovial sheath.

The venous plexus on the dorsum of the hand is closely related to the underlying synovial sheaths in­vesting the extensor tendons. The sheaths extend 10 to 15 mm proximal to the upper margin of the extensor retinaculum and finally end at variable levels on the dorsal surface of the metacarpals. A near miss of the veins could deposit the injection within the tendon sheaths. Each patient gave a history of inadvertent in­jection of drug into the dorsum of the hand which was

proteins PPD test of hand fluid

followed by swelling, subsequent pain and stiffness in wrist and/or fingers, and functional disability of the hands (Table II). The pain and stiffness were of mild-to-moderate intensity and had been present for surprisingly long periods of time. Pain usually brought these patients in for treatment. On physical examina­tion their general condition was essentially normal ex­cept for cutaneous stigmata of chronic drug addiction. Locally, there was a swelling on the dorsum of the hand which was discrete, firm, tense, cystic, nontender, nonadherent to the surrounding structures, and movable upon contraction of the extensor tendons (Fig. 1). The hand had a lobulated appearance of compression by the rigid extensor retinaculum in four patients (Fig. 2). Roentgenologically, bones of the wrist, hand, and small joints of the fingers were unremarkable.

Two patients had weakness of extension at the metacarpophalangeal joints-one had limited exten­sion of the right index and long fingers, and the other had lost extension of the small finger.

Laboratory data presented in Table III, including leukocyte count, uric acid, latex fixation test (rheuma­toid factor for serum and synovial fluid), and C-reactive

628 Dhaliwal and Garnes

proteins did not point to rheumatoid tenosynovitis, gout, or suppurative phenomenon. Cultures of the sy­novial fluid obtained at surgery were negative for any bacterial growth.

Treatment

Under regional block anesthesia and tourniquet, synovectomy was performed in each patient. Three pa­tients were observed to have degenerated and frayed extensor tendons (Fig. 3). The treatment of the patients with tendon involvement is partial tendon resection and anastomosis.

Postoperatively, the involved hands were immobi­lized in a plaster cast for 2 to 6 weeks depending upon the extent of extensor tendon damage. All of these pa­tients made an uneventful recovery.

Pathologic findings

The synovial sheaths showed fibrosis and thickening, variable sites of necrosis, and a pale yellow-to-brown discoloration, depending upon the duration of the reac­tion and the amount of hemorrhage. Also noticed were clear yellow-to-turbid mucoid synovial fluid and rice bodies floating free in the synovial fluid and adherent to the sheath.

Microscopically, in each case, there were multiple areas of degeneration surrounded by a zone of inflam­mation. The infiltrate consisted of plasma cells and lymphocytes. Some areas showed granuloma formation resembling those seen in rheumatoid synovitis (syno­vial lining thrown into hypertrophic villous folds over­run by collections of lymphocytes and macrophages).

Crystalline material was present in all cases. The crystals were birefringent foreign bodies, suggestive of carbohydrate particles. The crystalline material was deposited along the lining of the synovial sheath or in

The Journal of HAND SURGERY

the center of granuloma. Similar pathologic findings have been reported by Jacob et al. 10

Summary

Five patients with tenosynovitis secondary to inad­vertent injection of heroin with its diluents into the synovial sheaths investing the extensor tendons are pre­sented. Their clinical picture laboratory data and differ­ential diagnosis are discussed. The recommended treat­ment is synovectomy, partial tendon resection, and anastomosis when indicated.

The functional prognosis in these patients is excel­lent, at least in so far as their hands are concerned.

REFERENCES

I. Butterfield WC: Surgical complications of narcotic ad­diction. Surg Gynecol Obstet 134:237-40, 1972

2. Dunne JH, Johnson WC: Necrotizing skin lesions in he­roin addicts. Arch Dermatol 105:544, 1972

3. Hossey HH, Katx S: Infections resulting from narcotic addiction: Report of 102 cases. Am J Med 9:186, 1950

4. Lerner A, Derther FJ: Characteristics and sequelae of paragoric abuse. Ann Int Med 65: 10 19, 1966

5. Louria DB, Hensle T, Rose J: The major medical com­plications of heroin addiction. Ann lnt Med 67: I, 1967

6. Louria, DB: Cool talk about hot drugs. New York State Narcotic control commission, 1967

7. McCabe PW, Ditmars Jr DM: Soft tissue changes in the hands of drug addicts. Plast Reconstr Surg 52:538-40, 1973

8. Neviaser RJ, Butterfield WC, Wieche DR: The pudgy hand of drug addiction. J Bone Joint Surg [Am] 54:3, 1972

9. Vollum Dl: Skin lesions in drug addicts. Br J Med 2:647, 1970

10. Jacob HMD, Charyton C, Rascoff J, Golden R, Janis R: Amyloidosis secondary to drug abuse and chronic skin suppuration. Arch Intern Med 138:1150-3, 1978