Tenosynovitis is inflammation of synovial sheath that surrounds the tendons. It should be differentiated from term tendonitis which is inflammation of tendon itself.
Causes of Tenosynovitis
Tenosynovitis can occur from infection or noninfectious causes.
Non-infectious causes include diabetes, rheumatoid arthritis, crystalline deposition disease, ochronosis, amyloidosis, psoriatic arthritis, systemic lupus erythematosus, sarcoidosis, rheumatoid arthritis, scleroderma, Reiter’s syndrome or reactive arthritis, gonorrhea, and overuse.
Usually, the infectious tenosynovitis is incited by a piercing trauma like bite wound. The primary inciting event of infectious flexor tenosynovitis usually is penetrating trauma, such as a bite wound. Hematogenous spread may occur. Infecting organisms include the following
Staphylococcus aureus and Streptococcus [most common etiologic agents], Pasteurella multocida [mostly after a cat bite], Eikenella corrodens , anaerobes , Capnocytophaga canimorsus [ dog bites], Mycobacterium [bacteriae that cause TB], Clostridium difficile, Pseudomonas aeruginosa, Listeria monocytogenes, Vibrio vulnificus [stings from sea creatures], Neisseria gonorrhoeae [also called gonococcal tenosynovitis]
In some patients, the cause of the disease cannot be determined.
Certain tendons especially those in the hands, feet, and wrists are more susceptible to this condition. However, it can occur in any tendon in the body, including the shoulder, elbow, and knee.
Classification of Tenosynovitis [Michon]
- Stage I – Increased fluid in the sheath, mainly a serous exudate
- Stage II – Purulent fluid, granulomatous synovium
- Stage III- Necrosis of the tendon, pulleys, or tendon sheath
Clinical Presentation
Fever, chills, malaise, and polyarthralgias [pain in multiple joints] are common. The dorsum of the wrist, hand, and ankle are most commonly affected.
Gonococcal tenosynovitis most commonly affects teenagers and young adults. The onset of symptoms varies from 1 day to several weeks after sexual exposure. In nongonococcal infectious tenosynovitis, there may be a history of a puncture wound, laceration, bite or injection injury.
In non gonococcal flexor tenosynovitis of hand Kanavel signs of are noted which are
- Finger held in slight flexion
- Fusiform swelling
- Tenderness along the flexor tendon sheath
- Pain with passive extension of the digit
Kanavel signs may be absent in patients who have received antibiotics recently, early stage of disease, immunocompromised state, and chronic infections.
Erythema [redness], tenderness, and painful range of motion of the involved tendon are present. Hemorrhagic macules or papules may be present in a gonococcal infection.
Herpetic whitlow, pyarthrosis, gout, pseudogout, dactylitis, injury, arthritis, rheumatic fever, and subcutaneous abscess should be ruled out in flexor tenosynovitis of hand.
In inflammatory tenosynovitis, swelling is the most common initial finding. As the tissue expands and impingement occurs, pain and restricted motion ensue.
De Quervain tenosynovitis occurs because of inflammation of abductor pollicis longus and the extensor pollicis brevis tendons in the first dorsal compartment of the wrist at the lateral border of the anatomic snuffbox. Patients usually have a history of repetitive pinching motion of the thumb and fingers as in screwing or weeding. There is a gradual onset of pain in the radial aspect of the wrist which worsens with activity and becomes better with rest.
Finkelstein test is performed by having the patient make a fist with the thumb inside the fingers. Forceful ulnar deviation of the wrist reproduces dorsolateral wrist pain. This test is characteristic in de Quervain’s disease.
Volar flexor tenosynovitis or trigger finger mostly affects the thumb or ring finger in and is most common in middle-aged women. Higher incidence is noted in patients with diabetes. There is locking of the involved finger in flexion is followed by sudden release. Tenderness is present at the proximal end of the tendon sheath just proximal to the metacarpal head. Palpable tendon thickening and nodularity may be present.
Lab Studies
The white blood cell count may be elevated in the presence of proximal infection or systemic involvement but may be normal in inflammatory conditions and in immunocompromised patients.
The ESR typically is elevated in acute or chronic infections and may be elevated in cases of inflammatory flexor tenosynovitis (FT) as well. In case of infections, the decline of ESR marks resolution of infection.
Test for a rheumatoid factor if rheumatoid arthritis is a consideration.
A synovial biopsy may reveal acute or chronic inflammatory changes. Gram stains may reveal bacteria.
Diagnostic arthrocentesis is indicated if the joint effusion is present with tenosynovitis.
In noninfectious conditions, synovial fluid may show nonbirefringent crystals (gout) or birefringent crystals (calcium pyrophosphate disease [CPPD], or pseudogout).
In case of suspected infection, the culture of the synovial fluid [aerobic, anaerobic, fungal, mycobacteriae] is done before the patient is put on antibiotics. Gonococcal cultures of the urethra or cervix, rectum, and pharynx are appropriate if gonococcal tenosynovitis is suspected.
Imaging studies
Bony involvement may be ruled out by standard anteroposterior and lateral radiographs. Further imaging is generally not necessary.
Treatment of Synovitis
Noninfectious flexor tenosynovitis frequently is treated nonoperatively, but in chronic conditions, surgical intervention may be necessary.
For Gonococcal tenosynovitis, parenteral [injectable] antibiotics like ceftriaxone are given. Surgical drainage may be done if patient 48 hours of therapy.
For nongonococcal infections, urgent surgical incision and drainage is considered though prompt medical management [IV antibiotics, elevation, splinting] may preclude the need for surgical intervention.
For persistent infection, repeat operative debridement may be required.
For patients who are immunocompromised or have diabetes, early surgical intervention is warranted.
The surgical procedure depends on disease stage [Michon]
- Stage I – Catheter irrigation
- Stage II – Minimal invasive drainage +/- indwelling catheter irrigation
- Stage III – Extensive open débridement and possible amputation
For De Quervain tenosynovitis rest, nonsteroidal anti-inflammatory drugs, and a thumb spica wrist splint is given. Peritendinous lidocaine/corticosteroid injection is also considered for de Quervain tenosynovitis.
Peritendinous lidocaine/corticosteroid injection is the treatment of choice for volar flexor tenosynovitis or trigger finger. Simple splinting appropriate for patients who do not want to have a steroid injection.
Consider surgical tendon release if injection fails.
In tenosynovitis of Rheumatoid arthritis ice, NSAIDs, rest, splinting, DMARDs, oral steroid treatment may be considered.
