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Emergency and Acute Medicine - Tenosynovitis
Tenosynovitis refers to inflammation of a tendon and its surrounding synovial sheath, which normally functions to lubricate and facilitate smooth tendon movement through osseofibrous tunnels. This condition may arise from overuse, inflammatory processes, or infection. The synovial sheath consists of visceral and parietal layers that nourish the tendon, but it also creates a confined space where infection can rapidly spread. Infection may occur through direct inoculation from a skin wound, penetrating injury, or high-pressure injection, or via hematogenous spread. Flexor tenosynovitis of the hand is particularly concerning and is most often infectious in origin, commonly resulting from penetrating injuries at the finger flexion creases. High-pressure injection injuries, such as those from paint sprayers or air tools, may appear minor externally but carry a high risk of severe underlying damage and infection.
The causes of tenosynovitis vary depending on the type. Overuse-related conditions such as De Quervain tenosynovitis involve inflammation of the abductor pollicis longus and extensor pollicis brevis tendons as they pass through a fibrous sheath at the radial styloid. Infectious causes include gonococcal tenosynovitis, typically seen in young adults and associated with disseminated infection, and nongonococcal infections, most commonly due to Staphylococcus aureus or Streptococcus species. Other organisms may be involved depending on the exposure, such as Pasteurella multocida in cat bites, Eikenella corrodens in human bites, Pseudomonas in immunocompromised or marine injuries, and even mycobacterial or fungal pathogens in specific settings.
The hallmark of infectious flexor tenosynovitis is the presence of the four Kanavel signs: fusiform swelling of the finger (often described as a “sausage digit”), tenderness along the course of the flexor tendon sheath, pain with passive extension of the finger, and a flexed resting posture of the digit. These findings indicate a surgical emergency. In contrast, inflammatory forms such as De Quervain tenosynovitis present with pain over the radial aspect of the wrist that worsens with thumb movement and improves with rest. The Finkelstein test reproduces pain when the thumb is flexed into the palm and the wrist is deviated ulnarly. Gonococcal tenosynovitis often presents with systemic symptoms such as fever, chills, and migratory joint pain, sometimes accompanied by characteristic skin lesions.
Diagnosis is primarily clinical, based on history and physical examination. It is essential to assess for risk factors such as recent trauma, puncture wounds, bites, high-pressure injuries, or sexually transmitted infections. Neurovascular status should always be documented. Laboratory studies, including complete blood count and inflammatory markers, may support the diagnosis of infection. Cultures are important in suspected gonococcal disease. Imaging is generally of limited utility but may help identify foreign bodies or complications; MRI can assist in uncertain cases but is rarely required in the emergency setting.
Management depends on the underlying cause and urgency of the condition. All suspected infectious flexor tenosynovitis cases require immediate consultation with a hand surgeon, initiation of broad-spectrum intravenous antibiotics, and often surgical intervention. Delays in treatment significantly increase the risk of permanent functional impairment. High-pressure injection injuries are also surgical emergencies requiring urgent evaluation and intervention.
Inflammatory tenosynovitis is typically managed conservatively with rest, immobilization, elevation, nonsteroidal anti-inflammatory drugs, and splinting, such as a thumb spica splint for De Quervain tenosynovitis. Corticosteroid injections may be considered for persistent symptoms. Gonococcal tenosynovitis requires hospital admission and intravenous antibiotic therapy, while nongonococcal infections require broad antimicrobial coverage tailored to likely pathogens and patient risk factors.
Disposition is determined by severity and etiology. Infectious and high-risk cases require hospital admission and often surgical management, whereas noninfectious inflammatory cases can usually be managed on an outpatient basis with close follow-up. Early recognition, especially of Kanavel signs and high-risk mechanisms, is critical, as prompt treatment significantly improves outcomes and preserves function.
Tenosynovitis refers to inflammation of a tendon and its surrounding synovial sheath, which normally functions to lubricate and facilitate smooth tendon movement through osseofibrous tunnels. This condition may arise from overuse, inflammatory processes, or infection. The synovial sheath consists of visceral and parietal layers that nourish the tendon, but it also creates a confined space where infection can rapidly spread. Infection may occur through direct inoculation from a skin wound, penetrating injury, or high-pressure injection, or via hematogenous spread. Flexor tenosynovitis of the hand is particularly concerning and is most often infectious in origin, commonly resulting from penetrating injuries at the finger flexion creases. High-pressure injection injuries, such as those from paint sprayers or air tools, may appear minor externally but carry a high risk of severe underlying damage and infection.
The causes of tenosynovitis vary depending on the type. Overuse-related conditions such as De Quervain tenosynovitis involve inflammation of the abductor pollicis longus and extensor pollicis brevis tendons as they pass through a fibrous sheath at the radial styloid. Infectious causes include gonococcal tenosynovitis, typically seen in young adults and associated with disseminated infection, and nongonococcal infections, most commonly due to Staphylococcus aureus or Streptococcus species. Other organisms may be involved depending on the exposure, such as Pasteurella multocida in cat bites, Eikenella corrodens in human bites, Pseudomonas in immunocompromised or marine injuries, and even mycobacterial or fungal pathogens in specific settings.
The hallmark of infectious flexor tenosynovitis is the presence of the four Kanavel signs: fusiform swelling of the finger (often described as a “sausage digit”), tenderness along the course of the flexor tendon sheath, pain with passive extension of the finger, and a flexed resting posture of the digit. These findings indicate a surgical emergency. In contrast, inflammatory forms such as De Quervain tenosynovitis present with pain over the radial aspect of the wrist that worsens with thumb movement and improves with rest. The Finkelstein test reproduces pain when the thumb is flexed into the palm and the wrist is deviated ulnarly. Gonococcal tenosynovitis often presents with systemic symptoms such as fever, chills, and migratory joint pain, sometimes accompanied by characteristic skin lesions.
Diagnosis is primarily clinical, based on history and physical examination. It is essential to assess for risk factors such as recent trauma, puncture wounds, bites, high-pressure injuries, or sexually transmitted infections. Neurovascular status should always be documented. Laboratory studies, including complete blood count and inflammatory markers, may support the diagnosis of infection. Cultures are important in suspected gonococcal disease. Imaging is generally of limited utility but may help identify foreign bodies or complications; MRI can assist in uncertain cases but is rarely required in the emergency setting.
Management depends on the underlying cause and urgency of the condition. All suspected infectious flexor tenosynovitis cases require immediate consultation with a hand surgeon, initiation of broad-spectrum intravenous antibiotics, and often surgical intervention. Delays in treatment significantly increase the risk of permanent functional impairment. High-pressure injection injuries are also surgical emergencies requiring urgent evaluation and intervention.
Inflammatory tenosynovitis is typically managed conservatively with rest, immobilization, elevation, nonsteroidal anti-inflammatory drugs, and splinting, such as a thumb spica splint for De Quervain tenosynovitis. Corticosteroid injections may be considered for persistent symptoms. Gonococcal tenosynovitis requires hospital admission and intravenous antibiotic therapy, while nongonococcal infections require broad antimicrobial coverage tailored to likely pathogens and patient risk factors.
Disposition is determined by severity and etiology. Infectious and high-risk cases require hospital admission and often surgical management, whereas noninfectious inflammatory cases can usually be managed on an outpatient basis with close follow-up. Early recognition, especially of Kanavel signs and high-risk mechanisms, is critical, as prompt treatment significantly improves outcomes and preserves function.
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