• Clinical science

Tenosynovitis

Abstract

Tenosynovitis is the inflammation of a tendon (tendinitis) and its synovial sheath (synovitis). This inflammation is often due to tendon overuse (e.g., texting, typing), but can also be due to systemic diseases (e.g., rheumatoid arthritis, sarcoidosis) or infection following a penetrating injury (e.g., animal/human bites, thorn prick injury). The tendons of the hand and wrist are most commonly affected. Patients typically present with pain which is worsened by activity, edema of the affected tendons, and pain along the tendon course on stretching of the tendon. The diagnosis is established clinically but may require additional pathogen isolation for treatment planning in cases of bacterial tenosynovitis. Administration of NSAIDs and immobilization of the affected tendons is often sufficient for treating tenosynovitis. In cases of severe or persistent symptoms glucocorticoid injections into the tendon sheath are usually effective. Few cases require surgical splitting of the constricting ligaments of the affected tendons.

Etiology

References:[1][2]

Clinical features

  • Tendons of fingers and wrist are commonly affected
  • First sign: pain on passive extension of the affected tendon, finger slightly flexed at rest
  • Swelling, also fever and erythema in bacterial infections
  • Palpable crepitation
  • Late sign : tenderness along the affected tendon; sharp, stabbing pain worsened by activity, followed by constant dull ache at rest

Subtypes and variants

Stenosing tenosynovitis (trigger finger)

  • Epidemiology
    • Sex: > (6:1)
    • Age: > 40 years
  • Etiology: see “Etiology” section in stenosing tenosynovitis
  • Pathophysiology: inflammation and hypertrophy (stenosis) of the A1 annular pulley → loss of smooth gliding of the finger flexor tendons under the annular pulley → finger gets locked in flexed position
  • Clinical features
    • Trigger finger: painful locking of a finger in flexed position; releases suddenly with a snap/pop on extension
    • Often associated with tenderness and a palpable nodule at the base of the metacarpophalangeal joint
    • Mostly affects thumbs and ring fingers
  • Diagnostics: clinical diagnosis
  • Treatment: see below

De Quervain's tenosynovitis

References:[3][4][5]

Diagnostics

Tenosynovitis is a clinical diagnosis with specific tests used to establish the etiology.

  • Laboratory tests in infectious synovitis
  • X-ray: assessment of possible bone involvement, detection of a foreign body in cases of penetrating trauma
  • Tests for underlying disease if one is suspected (e.g., RA factor measurement, gonococcal cultures)

References:[1]

Treatment

  • Treatment of inflammatory tenosynovitis
    • Conservative management
      • NSAIDs
      • Splinting (immobilization) of the affected finger for 6 weeks
    • Interventions
      • Single (ultrasound-guided) glucocorticoid injection into the tendon sheath (effective in 90% cases, esp. if the tenosynovitis has been present for less than 6 months) .
      • Splitting of the constricting retinaculum/ligament
  • Treatment of infectious tenosynovitis
    • Analgesics and broad spectrum IV antibiotics (e.g., cephalosporins, clindamycin )
    • Splinting and elevation of the affected finger (to decrease the edema)
    • Surgery: incision and drainage + saline irrigation, open debridement of necrotic/infected tissue

References:[3][1][4][5][2]