Basics
Description
- Definition
- Inflammation of the tendon and tendon sheath
- Caused by inflammation, overuse, or infection
- Synovial sheaths cover tendons as they pass through osseofibrous tunnels:
- Visceral and parietal layers of the synovium lubricate and nourish the tendons.
- Infection can be introduced into tendon sheath.
- Skin wound
- Hematogenous spread
- Flexor tenosynovitis (FTS) of hand:
- Typically infectious etiology
- Penetrating injury especially at flexion creases of the finger is the most common mechanism.
- High-pressure "injection " injury to fingers
- Air tools
- Paint sprayers
- Hydraulic equipment
- May appear minor on the surface but are associated with high incidence of FTS
Etiology
- De Quervain tenosynovitis:
- Caused by overuse
- Inflammatory in nature
- 2 thumb tendons: The abductor pollicis longus (APL) and extensor pollicis brevis (EPB).
- On their way to the thumb, the APL and EPB traverse side-by-side through a thick fibrous sheath that forms a tunnel at the radial styloid process
- GC tenosynovitis:
- Nongonococcal infectious tenosynovitis:
- Staphylococcus aureus and Streptococci are most common in penetrating injuries.
- Pasteurella multocida is common with cat bites.
- Eikenella corrodens is common in human bites.
- Pseudomonas is seen in patients with diabetes or marine-associated injuries.
- Mycobacterium species may occur in immunocompromised patients.
- Fungal tenosynovitis may occur from puncture wounds due to thorns or woody plants
Diagnosis
Signs and Symptoms
- Cardinal signs of Kanavel for FTS include:
- Tenderness and symmetric swelling along flexor tendon sheath (sausage digit)
- Flexed position of the digit
- Pain with passive extension of the finger
- Pain with palpation along the tendon sheath
Hand
- De Quervain tenosynovitis:
- Repetitive pinching motion of thumb and fingers
- Assembly-line workers
- Carpenters
- Landscaping or weeding
- Pain in the radial aspect of the wrist becomes worse with activity and better with rest.
- Pain occurs on palpation along the radial aspect of the wrist.
- Pain occurs with passive range of motion of the thumb.
- Finkelstein test:
- Pain occurs with ulnar deviation of the wrist with the thumb cupped in a closed fist.
- GC tenosynovitis:
- Most commonly affects teenagers, young adults
- Seen in the ankle, hand, or wrist
- More commonly seen in women
- Vaginal or penile discharge usually absent
- Fever, chills, polyarthralgia are common.
- Erythema, tenderness to palpation, and painful range of motion of the involved tendon
- Dermatitis may be present.
- Hemorrhagic macules or papules on the distal extremities or trunk
Forearm
Traumatic tenosynovitis is seen after a direct blow to the lower portion of the forearm.
Ankle
- Stenosing tenosynovitis:
- Commonly seen at the inferior retinaculum of the peroneus tendon
- Patients are usually >40 yr old and have some predisposing trauma.
- Motion increases the pain.
- Rheumatoid tenosynovitis:
- Medially, the posterior tibial and flexor hallucis longus tendons are commonly involved.
- Laterally, the peronei are involved.
- Anteriorly, the anterior tibial tendon is involved.
- Motion increases the pain.
- Spontaneous rupture may occur.
History
- Assess for infectious etiology:
- History of sexually transmitted disease exposure, penile or vaginal discharge
- Obtain history of mechanism:
- High-pressure injections
- Puncture wounds, bites
- Environmental exposures
- Assess tetanus status and comorbid factors (e.g., diabetes and immunocompromised).
Physical Exam
- Assess Kanavel signs.
- Document neurovascular status.
- Tubular swelling of the tendon sheath if acute tenosynovitis is present.
- Identify signs and symptoms of systemic illness as well as other potential sites of infection.
Essential Workup
Thorough history and physical exam will often lead to appropriate diagnosis.
Diagnosis Tests & Interpretation
Lab
- CBC, ESR:
- May be of assistance in infectious etiology
- GC cultures (urethra, cervix, rectum, or pharynx) may be useful.
- Liver function tests may be elevated with disseminated N. gonorrhea infection.
Imaging
- Radiographs are low yield, unless a retained radiopaque soft tissue foreign body is suspected.
- MRI has proven accurate in assisting the diagnosis of tenosynovitis:
- Generally unnecessary in ED
Diagnostic Procedures/Surgery
NA
Differential Diagnosis
- Ankle, soft tissue injuries
- Bursitis
- Carpal tunnel syndrome
- Cellulitis
- Compartment syndrome
- Endocarditis
- Felon
- Gonorrhea
- Gout and pseudogout
- Hand infections
- High-pressure hand injuries
- Soft tissue hand injuries
- Soft tissue knee injuries
- Reiter syndrome
- Rheumatic fever
- Rheumatoid arthritis
Treatment
Pre-Hospital
- Delay to definitive treatment leads to significant increased morbidity and loss of function.
- Elevation and immobilization of the affected extremity should be performed.
Initial Stabilization/Therapy
- Manage airway and resuscitate as indicated:
- Elevation, immobilization of affected extremity
- IV access
- Tetanus status
- Procedure
- Diagnostic arthrocentesis is indicated if joint effusion is present with tenosynovitis:
- Most patients with disseminated GC infection have coexisting septic arthritis.
- Cultures are negative in 50% of patients.
- 25% GC arthritis is polyarticular.
- Joint fluid glucose is normal.
- WBCs usually are <50,000 and a Gram stain is positive in 25% of the patients.
Ed Treatment/Procedures
Hand
- High-pressure injection injuries to hand:
- Surgical emergency
- Immediate hand surgery consultation
- Pain management
- Infectious FTS of hand:
- Immediate hand surgery consultation
- Broad-spectrum antibiotic coverage
- De Quervain tenosynovitis:
- Rest, NSAID agents, and thumb spica splint
- Consider lidocaine/corticosteroid injection if condition is unresponsive.
- Phonophoresis (application of hydrocortisone gel to the radial styloid area daily) helps relieve pain in minor cases.
- GC tenosynovitis:
- Admit for IV antibiotic therapy.
- Penicillin or 1st-generation cephalosporins for initial therapy
- 2nd-generation cephalosporins as an alternative
- Surgical drainage may be indicated if antibiotics do not improve the condition.
- Pain management
- Nongonococcal infectious tenosynovitis:
- If diagnosis is equivocal, the patient should receive IV antibiotic therapy and consultation with a hand surgeon.
- Cover for Staphylococcus, Streptococcus, as well as anaerobic bacterial infection.
- Consider coverage for Pseudomonas for the diabetic or immunocompromised patient.
- Aminoglycosides may be added for double coverage.
- Pain management
Forearm
- Traumatic tenosynovitis:
- Rest, ice, elevation, immobilization
- NSAIDs
Ankle
- Stenosing tenosynovitis:
- Rest, ice, elevation, immobilization
- NSAIDs
- Rheumatoid tenosynovitis:
- Rest, ice, elevation, immobilization
- NSAIDs
Medication
- Cefazolin: 1 " 2 g IV q8h (peds: 50 " 100 mg/kg/d IV div. q8h)
- Cefotetan: 1 " 2 g IV q12h (peds: 50 " 100 mg/kg/d IV div. q12h)
- Cefoxitin: 1 " 2 g IV q8h (peds: 80 " 160 mg/kg/d IV div. q6 " 8h)
- Ceftriaxone: 1 " 2 g IV q12h (peds: 50 " 100 mg/kg/d IV div. q12h)
- Clindamycin: 600 " 900 mg IV q8h (peds: 20 " 40 mg/kg/d div. q8h)
- Penicillin G: 12 " 24 mIU IV div. q4 " 6h (peds: 100,000 " 400,000 IU/kg/d IV div. q4 " 6h)
- Timentin: 3.1 g IV q6h (peds: 200 " 300 mg/kg/d IV div. q4 " 6h)
- Tobramycin: 1 mg/kg IV q8h or 5 mg/kg IV q24h (peds: 2 " 2.5 mg/kg IV q8h)
- Zosyn: 3.375 g IV q6h (peds: 200 " 400 mg/kg/d IV div. q6 " 8h)
Follow-Up
Disposition
- Patients with FTS require immediate consultation with a hand specialist and admission.
- Patients presenting 24 " 48 hr may have more conservative therapy to include immobilization, elevation IV antibiotics, and close observation.
- Surgical debridement indicated if patient is not improved within the 1st 24 hr, or physical findings are not resolved within 48 hr.
- Patients presenting longer than 48 hr require surgical debridement in the operating room.
- The hand surgeon may attempt continuous catheter irrigation of the tendon sheath.
Admission Criteria
Infectious or high-pressure etiologies for tenosynovitis should be admitted.
Discharge Criteria
Inflammatory etiologies can be managed as outpatients with appropriate referral.
Issues for Referral
Stenosing and rheumatoid tenosynovitis
Followup Recommendations
Patients whose etiology is inflammatory should be referred for follow-up within 1 " 2 wk
Pearls and Pitfalls
- High-pressure injection injuries may have subtle clinical findings, small puncture wounds
- Early hand surgeon consultation for suspected infectious etiology or high-pressure injection injuries is paramount
- De Quervain tenosynovitis may require thumb spica immobilization in order to improve
Additional Reading
- Baskar S, Mann JS, Thomas AP, et al. Plant thorn tenosynovitis. J Clin Rheumatol. 2006;12:137 " 138.
- Mehdinasab SA, Alemohammad SA. Methylprednisolone acetate injection plus casting versus casting alone for the treatment of de Quervains tenosynovitis. Arch Iran Med. 2010;13:270 " 274.
- Torralba KD, Quismorio FP Jr. Soft tissue infections. Rheum Dis Clin North Am. 2009;35(1):45 " 62.
Codes
ICD9
- 727.00 Synovitis and tenosynovitis, unspecified
- 727.04 Radial styloid tenosynovitis
- 727.05 Other tenosynovitis of hand and wrist
- 098.51 Gonococcal synovitis and tenosynovitis
- 727.06 Tenosynovitis of foot and ankle
- 727.09 Other synovitis and tenosynovitis
ICD10
- M65.4 Radial styloid tenosynovitis [de Quervain]
- M65.849 Other synovitis and tenosynovitis, unspecified hand
- M65.9 Synovitis and tenosynovitis, unspecified
- A54.49 Gonococcal infection of other musculoskeletal tissue
- M65.839 Other synovitis and tenosynovitis, unspecified forearm
- M65.879 Other synovitis and tenosynovitis, unsp ankle and foot
SNOMED
- 67801009 Tenosynovitis (disorder)
- 423778009 tenosynovitis of hand (disorder)
- 21794005 Radial styloid tenosynovitis
- 240039005 Gonococcal tenosynovitis (disorder)
- 202907005 Tenosynovitis of ankle (disorder)
- 202912006 Flexor tenosynovitis of finger (disorder)
- 202915008 Extensor tenosynovitis of finger (disorder)