Tenosynovitis

Last updated
Tenosynovitis
Other names tendosynovitis
Tenosynovitis-3.JPG
Congenital stenosing tenosynovitis of the thumb in a 3-year-old child. The thumb is unable to be straightened.
Specialty Physical medicine and rehabilitation   OOjs UI icon edit-ltr-progressive.svg

Tenosynovitis is the inflammation of the fluid-filled sheath (called the synovium) that surrounds a tendon, typically leading to joint pain, swelling, and stiffness. Tenosynovitis can be either infectious or noninfectious. Common clinical manifestations of noninfectious tenosynovitis include de Quervain tendinopathy and stenosing tenosynovitis (more commonly known as trigger finger). [1]

Contents

Signs and symptoms

Infectious tenosynovitis in 2.5% to 9.4% of all hand infections. Kanavel's cardinal signs are used to diagnose infectious tenosynovitis. They are: tenderness to touch along the flexor aspect of the finger, fusiform enlargement of the affected finger, the finger being held in slight flexion at rest, and severe pain with passive extension. [2] [3] Fever may also be present, but is uncommon. [4]

Pathogenesis

Infectious tenosynovitis is the infection of closed synovial sheaths in the flexor tendons of the fingers. It is usually caused by trauma, but bacteria can spread from other sites of the body. Although tenosynovitis usually affects the flexor tendon of the fingers, the disease can also affect the extensor tendons occasionally. [5] The clinical presentation is therefore as acute infection following trauma. The infection can be mono- or polymicrobial and can vary depending on the nature of the trauma. The most common pathogenic agent is Staphylococcus aureus introduced from the skin. [6] Other bacteria linked to infectious tenosynovitis include Pasteurella multocida (associated with animal bites), Eikenella spp. (associated with IV drug use), and Mycobacterium marinum (associated with wounds exposed to fresh or salt water). [7] Additionally, sexually active patients are at risk for hematogenous spread due to Neisseria gonorrhoeae (see infectious arthritis).

Common noninfectious tenosynovitis are: stenosing tenosynovitis, intersection syndrome, extensor pollicis longus (EPL) tenosynovitis, de Quervain's and fourth compartment tenosynovitis. [8]

Diagnosis

Diagnosis of tenosynovitis is typically made clinically after a thorough patient history and physical exam. Aspirated fluid can also be cultured to identify the infectious organism. X-rays are typically unremarkable but can help rule out a broken bone or a foreign body [1]

Treatment

The mainstay of treatment for infectious tenosynovitis includes symptom relief, antibiotic therapy, and surgery. Early recognition of the disease with early initiation of antibiotics are important for better range of movement of the affected finger. Minimally invasive procedures into the flexor tendon sheath such as catheter irrigation give better outcomes (74% chance of good outcome) when compared to open surgery (26% chance of good outcome). However, wound irrigation with antibiotics has no clear benefits. [2] Most infectious tenosynovitis cases should be managed with tendon sheath irrigation and drainage, with or without debridement of surrounding necrotic tissue, along with treatment with broad-spectrum antibiotics. [5] In severe cases, amputation may even be necessary to prevent the further spread of infection. Following surgical intervention, antibiotic therapy is continued and adjusted based on the results of the fluid culture. [5]

Prognosis

The earlier the condition is identified, the better the chance of getting full range of motion of the finger. However, finger stiffness, Boutonniere deformity, deep space infection, tendon necrosis, adhesions, persistent infection, and need for amputation of the finger can occur. Tendon adhesion and finger stiffness are caused by the violation of the flexor tendon sheath. [2]

See also

Notes

  1. 1 2 Sexton, MD, Daniel. "Infectious Tenosynovitis". Uptodate.
  2. 1 2 3 Avira M, Giladi; Sunitha, Malay; Kevin, C Chung (23 March 2016). "Management of acute pyogenic flexor tenosynovitis: Literature review and current trends". Journal of Hand Surgery (European Volume). 40 (7): 720–728. doi:10.1177/1753193415570248. PMC   4804717 . PMID   25670687.
  3. Pang, HN; Teoh, LC; Yam, AK; Lee, JY; Puhaindran, ME; Tan, AB (August 2007). "Factors affecting the prognosis of pyogenic flexor tenosynovitis". The Journal of Bone and Joint Surgery. American Volume. 89 (8): 1742–8. doi:10.2106/JBJS.F.01356. PMID   17671013.
  4. Nikkhah, D; Rodrigues, J; Osman, K; Dejager, L (2012). "Pyogenic flexor tenosynovitis: one year's experience at a UK hand unit and a review of the current literature". Hand Surgery. 17 (2): 199–203. doi:10.1142/S0218810412500190. PMID   22745083.
  5. 1 2 3 Small, LN; Ross, JJ (December 2005). "Suppurative tenosynovitis and septic bursitis". Infectious Disease Clinics of North America. 19 (4): 991–1005, xi. doi:10.1016/j.idc.2005.08.002. PMID   16297744.
  6. Moses MD, Scott. "Suppurative Tenosynovitis". www.fpnotebook.com.
  7. Tsai, E; Failla, JM (May 1999). "Hand infections in the trauma patient". Hand Clinics. 15 (2): 373–86. doi:10.1016/S0749-0712(21)00470-4. PMID   10361644.
  8. Travis, D Blood; Nathan T, Morrell; Arnold Peter, C Weiss (29 March 2016). "Tenosynovitis of the Hand and Wrist". Journal of Bone and Joint Surgery. 4 (3): e71–e78. doi:10.2106/JBJS.RVW.O.00061. PMID   27500430. S2CID   29942149.

Related Research Articles

<span class="mw-page-title-main">De Quervain syndrome</span> Restricted movement of tendons controlling the thumb

De Quervain syndrome occurs when two tendons that control movement of the thumb become constricted by their tendon sheath in the wrist. This results in pain and tenderness on the thumb side of the wrist. Radial abduction of the thumb is painful. On some occasions, there is uneven movement or triggering of the thumb with radial abduction. Symptoms can come on gradually or be noted suddenly.

<span class="mw-page-title-main">Trigger finger</span> Locking of a finger when at full flexion

Trigger finger, also known as stenosing tenosynovitis, is a disorder characterized by catching or locking of the involved finger in full or near full flexion, typically with force. There may be tenderness in the palm of the hand near the last skin crease. The name "trigger finger" may refer to the motion of "catching" like a trigger on a gun. The ring finger and thumb are most commonly affected.

<span class="mw-page-title-main">Septic arthritis</span> Inflammation of a joint due to infection

Acute septic arthritis, infectious arthritis, suppurative arthritis, pyogenic arthritis, osteomyelitis, or joint infection is the invasion of a joint by an infectious agent resulting in joint inflammation. Generally speaking, symptoms typically include redness, heat and pain in a single joint associated with a decreased ability to move the joint. Onset is usually rapid. Other symptoms may include fever, weakness and headache. Occasionally, more than one joint may be involved, especially in neonates, younger children and immunocompromised individuals. In neonates, infants during the first year of life, and toddlers, the signs and symptoms of septic arthritis can be deceptive and mimic other infectious and non-infectious disorders.

<span class="mw-page-title-main">Psoriatic arthritis</span> Long-term inflammatory arthritis

Psoriatic arthritis (PsA) is a long-term inflammatory arthritis that occurs in people affected by the autoimmune disease psoriasis. The classic feature of psoriatic arthritis is swelling of entire fingers and toes with a sausage-like appearance. This often happens in association with changes to the nails such as small depressions in the nail (pitting), thickening of the nails, and detachment of the nail from the nailbed. Skin changes consistent with psoriasis frequently occur before the onset of psoriatic arthritis but psoriatic arthritis can precede the rash in 15% of affected individuals. It is classified as a type of seronegative spondyloarthropathy.

<span class="mw-page-title-main">Osteomyelitis</span> Infection of the bones

Osteomyelitis (OM) is an infection of bone. Symptoms may include pain in a specific bone with overlying redness, fever, and weakness. The long bones of the arms and legs are most commonly involved in children e.g. the femur and humerus, while the feet, spine, and hips are most commonly involved in adults.

<span class="mw-page-title-main">Limp</span> Type of asymmetric abnormality of the gait

A limp is a type of asymmetric abnormality of the gait. Limping may be caused by pain, weakness, neuromuscular imbalance, or a skeletal deformity. The most common underlying cause of a painful limp is physical trauma; however, in the absence of trauma, other serious causes, such as septic arthritis or slipped capital femoral epiphysis, may be present. The diagnostic approach involves ruling out potentially serious causes via the use of X-rays, blood tests, and sometimes joint aspiration. Initial treatment involves pain management. A limp is the presenting problem in about 4% of children who visit hospital emergency departments.

<span class="mw-page-title-main">Nintendo thumb</span> Injury caused by video games

Nintendo thumb, also known as gamer's thumb and similar names, is a form of repetitive strain injury (RSI) caused by excessive playing of video games with the traditional Nintendo controller. This injury mainly occurs due to repeated thumb movements while playing video games. The symptoms can include blistering, paraesthesia, as well as swelling of the thumbs, though any finger can be affected. This can lead to stress on tendons, nerves, and ligaments in the hands, and further onto lateral epicondylitis, tendinitis, bursitis, and carpal tunnel syndrome. Similar injuries can occur with other gaming systems, such as PlayStation thumb from playing Sony PlayStation. The general recommendation for the treatment is to rest and stop the repetitive motion of the affected finger. In more severe and painful cases, using NSAIDs is also recommended.

In human anatomy, the extensor pollicis longus muscle (EPL) is a skeletal muscle located dorsally on the forearm. It is much larger than the extensor pollicis brevis, the origin of which it partly covers and acts to stretch the thumb together with this muscle.

<span class="mw-page-title-main">Finkelstein's test</span> Test used to diagnose de Quervains tenosynovitis

Finkelstein's test is a test used to diagnose de Quervain's tenosynovitis in people who have wrist pain.

<span class="mw-page-title-main">Interphalangeal joints of the hand</span> Hinge joints between finger phalanges

The interphalangeal joints of the hand are the hinge joints between the phalanges of the fingers that provide flexion towards the palm of the hand.

<span class="mw-page-title-main">Boutonniere deformity</span> Medical condition

Boutonniere deformity is a deformed position of the fingers or toes, in which the joint nearest the knuckle is permanently bent toward the palm while the farthest joint is bent back away. Causes include injury, inflammatory conditions like rheumatoid arthritis, and genetic conditions like Ehlers-Danlos syndrome.

<span class="mw-page-title-main">Transient synovitis</span> Inflammation of the inner lining (synovium) of the hip joint capsule

Transient synovitis of hip is a self-limiting condition in which there is an inflammation of the inner lining of the capsule of the hip joint. The term irritable hip refers to the syndrome of acute hip pain, joint stiffness, limp or non-weightbearing, indicative of an underlying condition such as transient synovitis or orthopedic infections. In everyday clinical practice however, irritable hip is commonly used as a synonym for transient synovitis. It should not be confused with sciatica, a condition describing hip and lower back pain much more common to adults than transient synovitis but with similar signs and symptoms.

The posterior compartment of the forearm contains twelve muscles which primarily extend the wrist and digits. It is separated from the anterior compartment by the interosseous membrane between the radius and ulna.

An open fracture, also called a compound fracture, is a type of bone fracture that has an open wound in the skin near the fractured bone. The skin wound is usually caused by the bone breaking through the surface of the skin. An open fracture can be life threatening or limb-threatening due to the risk of a deep infection and/or bleeding. Open fractures are often caused by high energy trauma such as road traffic accidents and are associated with a high degree of damage to the bone and nearby soft tissue. Other potential complications include nerve damage or impaired bone healing, including malunion or nonunion. The severity of open fractures can vary. For diagnosing and classifying open fractures, Gustilo-Anderson open fracture classification is the most commonly used method. This classification system can also be used to guide treatment, and to predict clinical outcomes. Advanced trauma life support is the first line of action in dealing with open fractures and to rule out other life-threatening condition in cases of trauma. The person is also administered antibiotics for at least 24 hours to reduce the risk of an infection.

Kanavel's sign is a clinical sign found in patients with infection of a flexor tendon sheath in the hand, a serious condition which can cause rapid loss of function of the affected finger.

<span class="mw-page-title-main">Wrist pain</span>

Wrist pain or open wrist is a syndrome inhibiting use of a hand due to pain in anatomical structures of the wrist. It most commonly results from an injury to a ligament. The pain may be sharp from a traumatic injury or from chronic repetitive wrist activities.

The hand is a very complex organ with multiple joints, different types of ligament, tendons and nerves. Hand disease injuries are common in society and can result from excessive use, degenerative disorders or trauma.

<span class="mw-page-title-main">Viral arthritis (poultry)</span> Infectious disease of poultry

Viral arthritis is an infectious disease in poultry, such as chickens and turkeys, caused by Avian reovirus. Arthritis and tenosynovitis are the main signs of Avian reovirus infection in chickens, although the virus can cause other signs.

<span class="mw-page-title-main">Extensor tendon compartments of the wrist</span>

Extensor tendon compartments of the wrist are anatomical tunnels on the back of the wrist that contain tendons of muscles that extend the wrist and the digits.