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Corresponding author: Tricia Kuah, Mailing address: 1E Kent Ridge Road, National University Health System Tower Block Level 12, Singapore 119228, Phone number: +65 6779 5555, Fax: +65 6779 5678.
Department of Diagnostic Imaging, National University Health System, 1E Kent Ridge Rd, Tower Block Level 12, Singapore, 119228Radiology department, Qatif Central Hospital, Dhahran Jubail Branch Rd, Al Iskan, Al Qatif, 32654, Saudi Arabia
Department of Diagnostic Imaging, National University Health System, 1E Kent Ridge Rd, Tower Block Level 12, Singapore, 119228King Abdullah Medical Complex, Prince Nayef Street, Northern Abhor, Jeddah, 23816, Saudi Arabia
Department of Diagnostic Imaging, National University Health System, 1E Kent Ridge Rd, Tower Block Level 12, Singapore, 119228Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore, 117597
A 61-year-old man presented with erythematous and painful swelling of his left hand, wrist, and distal forearm for five days. He denied any penetrating injury and had no known inflammatory arthropathy or thrombophilia. There was no fluctuance or neurovascular compromise. Investigations revealed elevated leucocyte counts (14.11 × 109/L) and C-reactive protein (228 mg/L).
Radiographs demonstrated soft tissue swelling at the aforementioned areas (Figures 1A-B). Magnetic resonance imaging (Figures 2A-D) showed fluid and synovitis along the flexor tendon sheaths, predominantly involving the thumb and little finger, compatible with infective tenosynovitis. This was complicated by a rim-enhancing collection between the pronator quadratus and the flexor tendon sheath at the space of Parona (SOP). Tenosynovectomy and surgical drainage were performed. Cultures yielded Streptococcus agalactiae and the patient recovered uneventfully after six weeks of antibiotic therapy.
Figure 1Frontal (A) and lateral (B) radiographs of the left wrist. There is diffuse soft tissue swelling, most marked at the volar aspect (arrow in B). No soft tissue gas or bony abnormality is identified. Deformity of the distal radius is due to a remote healed fracture.
Figure 2MRI of the left wrist. Axial (A) and coronal (C), fat-suppressed, T2-weighted sequences and axial (B) and coronal (D), post-contrast, fat-suppressed, and T1-weighted sequences are shown. A T2-weighted hyperintense collection with rim enhancement (between the arrows in A and B) is demonstrated at the volar aspect of the distal forearm between the deep flexor tendons and the pronator quadratus (PQ) muscle (space of Parona). The coronal images (C and D) show fluid and synovitis along the flexor tendon sheath of the thumb (dashed arrow in D) with extension through the carpal tunnel (between the arrowheads in C) and a resultant Parona space collection (arrow in C).
). SOP collections are rare but potentially limb-threatening complications of pyogenic flexor tenosynovitis, particularly when the thumb and little finger are involved (
Approval was not required (images are anonymized).
Author contributions
Drs. Kuah, Al Moslem, Banjar: acquisition and interpretation of data, Drs. Kuah, Al Moslem: preparation of the manuscript, Dr. Hallinan: conceived the study concept, supervised data acquisition and interpretation, Drs. Kuah, Al Moslem, Banjar, and Hallinan: completion of the manuscript.
Sponsor's role
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interest
The authors have no competing interests to declare.
Acknowledgments
None.
References
Jamil W
Khan I
Robinson P
et al.
Acute Compartment Syndrome of the Forearm Secondary to Infection Within the Space of Parona.
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