Orthopaedic Surgery - Tenosynovitis

Basics

Tenosynovitis is a painful disorder involving:

Inflammation or irritation of a tendon and its surrounding synovial sheath.

It most often affects long tendons in the:

Fingers

Wrist

or

Ankle.

Causes

Tenosynovitis may result from:

Acute injury

Repetitive mechanical loading

Systemic inflammatory disease

Infection

or, in some patients,

No identifiable cause.

Age

The condition is uncommon in:

Children

and is seen most frequently during:

Early to middle adulthood.

Classification by Duration

Tenosynovitis may be described as:

Acute

or

Chronic.

Acute Tenosynovitis

Acute tenosynovitis generally produces symptoms lasting only:

Several days.

Noninfectious acute cases may improve relatively quickly with:

Activity modification

Rest

and

Anti-inflammatory treatment.

Chronic Tenosynovitis

Symptoms persisting longer than approximately:

2–3 weeks

may be considered chronic.

Chronic disease may be accompanied by greater:

Sheath thickening

Fibrosis

and

Tendon degeneration.

These cases may be more difficult to:

Resolve completely.

Common Locations

Frequent clinical forms include:

Posterior tibial tenosynovitis

Flexor tendon tenosynovitis of the hand

Biceps tenosynovitis

and

de Quervain tenosynovitis.

de Quervain Tenosynovitis

de Quervain disease affects the first dorsal extensor compartment, principally the:

Abductor pollicis longus

and

Extensor pollicis brevis tendons.

Synonym

The term:

Tendinitis

is sometimes used interchangeably, although tendinitis refers primarily to the:

Tendon itself

whereas tenosynovitis specifically involves the:

Synovial tendon sheath.

Prevention

Because many cases arise unpredictably, there is no reliable method for preventing all forms of:

Tenosynovitis.

Activity Modification

In patients whose symptoms are related to repetitive loading, prevention of recurrence may involve:

Ergonomic adjustment

Technique modification

and avoidance of abrupt increases in:

Repetitive activity.

Epidemiology

Tenosynovial disorders are among the more common:

Musculoskeletal complaints.

Many individuals experience at least one episode of tendon or tendon-sheath irritation during:

Their lifetime.

Sex

Women appear to be affected slightly more frequently than:

Men.

Risk Factors

Potential risk factors include:

Rheumatoid arthritis

Other inflammatory arthropathies

Previous tenosynovitis

Pregnancy

and selected repetitive:

Occupational or recreational activities.

Repetitive Motion

The relationship between repetitive motion and every form of tenosynovitis is not absolute.

However, repetitive loading may contribute in susceptible patients, especially when activity is:

New

Unusually intense

or associated with poor:

Biomechanics.

Etiology

Repeated use or mechanical constriction may irritate the:

Tendon sheath

causing thickening and impaired:

Tendon gliding.

Noninfectious Tenosynovitis

Many noninfectious cases occur in adults between approximately:

30 and 50 years of age

who perform repetitive:

Hand

Wrist

or

Lower-extremity activities.

Systemic Inflammatory Disease

Tenosynovitis may be a manifestation of:

Rheumatoid arthritis

Systemic lupus erythematosus

or other:

Inflammatory arthritides.

Infectious Tenosynovitis

Infection usually develops when bacteria gain access to the:

Tendon sheath

through:

Penetrating trauma

Laceration

Puncture wound

or, less commonly,

Hematogenous spread.

Flexor Tendon Sheath Infection

Infectious flexor tenosynovitis of the hand is particularly important because infection can spread rapidly within the:

Closed tendon sheath.

It represents an:

Urgent surgical condition.

Pregnancy Considerations

Pregnancy may precipitate or worsen:

Tenosynovitis

particularly:

de Quervain tenosynovitis.

Fluid retention and hormonal changes may contribute to:

Tendon-sheath swelling.

Associated Conditions

Important associated disorders include:

Rheumatoid arthritis

Lupus

and other:

Inflammatory arthropathies.

Diagnosis

Diagnosis is usually based on:

History

Physical examination

and, when necessary,

Laboratory or imaging studies.

Signs and Symptoms

The most common symptom is:

Pain along the course of the affected tendon.

Onset

Pain may develop:

Suddenly

or

Gradually.

It frequently follows a period of:

New or unusually strenuous activity.

Activity-Related Pain

Symptoms generally worsen with:

Use of the involved tendon

and improve with:

Rest.

Swelling

There may be localized:

Swelling

or fullness along the:

Tendon sheath.

Crepitus

Some patients develop palpable or audible:

Crepitus

as the tendon moves within an inflamed or thickened:

Sheath.

de Quervain Symptoms

de Quervain tenosynovitis typically causes:

Radial-sided wrist pain

near the:

Radial styloid.

Symptoms worsen with:

Thumb motion

Gripping

and

Ulnar deviation of the wrist.

Trigger Finger

Tenosynovial thickening around the flexor tendons may produce:

Trigger finger.

Triggering Mechanism

The tendon catches as it passes through a constricted:

Flexor pulley system.

This may produce:

Clicking

Snapping

or

Locking

during finger flexion or extension.

Physical Examination

The examination should identify the specific:

Tendon or tendon sheath

responsible for symptoms.

Tenderness

Tenderness is typically distributed:

Longitudinally

along the course of the:

Affected tendon.

Severity

Tenderness may be:

Mild

Moderate

or

Severe

depending on the underlying:

Cause and duration.

Swelling

Visible or palpable swelling may follow the:

Tendon sheath.

Crepitus With Motion

Moving the affected tendon may reproduce:

Pain

and occasionally:

Crepitus.

Range of Motion

Assess:

Active

and

Passive range of motion.

Restriction may result from:

Pain

Swelling

or mechanical:

Tendon constriction.

Infectious Flexor Tenosynovitis

When infection is suspected in a finger, look for the classic:

Kanavel signs.

These include:

Fusiform swelling of the digit

Tenderness along the flexor tendon sheath

Finger held in slight flexion

and

Pain with passive extension.

The presence of these findings should prompt:

Urgent surgical evaluation.

Laboratory Tests

Laboratory studies are not always required for uncomplicated noninfectious:

Tenosynovitis.

Suspected Infection

When infection is possible, useful studies may include:

Complete blood count

Erythrocyte sedimentation rate

and

C-reactive protein.

Systemic Disease Evaluation

Additional testing may be appropriate when symptoms suggest:

Rheumatoid arthritis

Lupus

Gout

or another systemic:

Inflammatory disorder.

Imaging

Plain Radiographs

Radiographs may be useful when there is:

Penetrating trauma

Suspected fracture

Adjacent arthritis

or another potential:

Bony cause of symptoms.

Radiographic Role

Plain films generally do not demonstrate the tendon-sheath inflammation directly.

They are primarily used to identify:

Alternative diagnoses

and associated:

Skeletal abnormalities.

Ultrasound

Ultrasound can demonstrate:

Tendon-sheath fluid

Synovial thickening

Tendon abnormalities

and dynamic:

Tendon motion.

MRI

MRI may show:

Fluid surrounding the tendon

Synovial thickening

Tendon degeneration

or associated:

Soft-tissue pathology.

Role of Advanced Imaging

Ultrasound or MRI is most helpful when:

The diagnosis is uncertain

Symptoms persist despite treatment

or a mass, tear, or other structural lesion is:

Suspected.

Pathological Findings

The pathological appearance varies according to the:

Cause.

Acute Inflammatory Disease

Acute inflammatory tenosynovitis may show:

Synovial edema

Hyperemia

and infiltration by:

Inflammatory cells.

Chronic Disease

Chronic cases may demonstrate:

Synovial thickening

Fibrosis

and degenerative changes affecting the:

Tendon.

Infectious Disease

Septic tenosynovitis may contain:

Purulent fluid

with marked:

Synovial inflammation

and potentially:

Tendon damage.

Differential Diagnosis

Important alternatives include:

Tendon strain

Partial tendon tear

Complete tendon rupture

Tendon-sheath infection

Arthritis

and other causes of regional:

Soft-tissue pain.

Treatment

Treatment depends on whether the process is:

Mechanical

Inflammatory

or

Infectious.

General Measures

Most uncomplicated noninfectious cases are initially treated with:

Relative rest

Activity modification

and gentle:

Range-of-motion exercises.

Relative Rest

The provoking activity should be reduced sufficiently to allow symptoms to:

Settle.

Complete inactivity is generally avoided when painless movement is:

Possible.

Immobilization

Short-term use of a:

Splint

or

Brace

may be helpful when symptoms are severe.

Prolonged immobilization should generally be avoided because it may lead to:

Stiffness

and

Weakness.

Physical and Occupational Therapy

Physical and occupational therapists may assist with:

Splinting

Stretching

Strengthening

and

Work or activity modification.

Ergonomic Modification

When occupational activity contributes to symptoms, therapy may focus on:

Tool modification

Workstation adjustment

and changes in:

Repetitive movement patterns.

Stretching

Gentle stretching can help maintain:

Tendon excursion

and surrounding:

Joint mobility.

Strengthening

Once acute pain improves, progressive strengthening may restore:

Tendon capacity

and reduce recurrence.

Medication

NSAIDs

NSAIDs may provide short-term relief of:

Pain

and

Inflammatory symptoms.

They are commonly used in:

Noninfectious tenosynovitis.

Corticosteroid Injection

Corticosteroid injection may be effective for selected disorders, particularly:

de Quervain tenosynovitis

and

Trigger finger.

Injection Precautions

Injection should be performed carefully to avoid:

Direct intratendinous injection

which can increase the risk of:

Tendon weakening or rupture.

Systemic Inflammatory Disease

Tenosynovitis caused by rheumatoid arthritis or another inflammatory disease may improve with:

Disease-modifying antirheumatic therapy

and appropriate systemic:

Anti-inflammatory treatment.

Infectious Tenosynovitis

Septic tenosynovitis requires:

Urgent treatment.

Antibiotics

Treatment includes prompt:

Intravenous or appropriately targeted antibiotics

based on the suspected organism and:

Culture results.

Surgery

Surgery may be required when:

Nonoperative treatment fails

or when mechanical compression prevents normal:

Tendon gliding.

Surgical Release

Operative treatment may involve:

Opening or releasing the tendon sheath

to relieve:

Constriction.

Synovectomy

Diseased or hypertrophic synovium may be:

Excised

to improve tendon:

Gliding.

Tendon Débridement

Degenerated tendon tissue may require:

Débridement

in selected chronic cases.

de Quervain Surgery

Persistent de Quervain disease may require complete release of the:

First dorsal extensor compartment.

Both the:

Abductor pollicis longus

and any separate compartment containing the:

Extensor pollicis brevis

must be adequately decompressed.

Postoperative Splinting

Temporary splinting may be used after surgery depending on:

Procedure

and

Tendon condition.

Septic Tenosynovitis Surgery

Infectious tenosynovitis may require urgent:

Tendon-sheath irrigation and decompression

with removal of:

Purulent material

and

Infected synovium.

Timing in Infection

Delay in treatment can lead to:

Tendon necrosis

Adhesions

Loss of motion

or spread of:

Infection.

Referral

Patients with suspected systemic inflammatory disease should be referred for appropriate:

Rheumatologic evaluation.

Rheumatology

Patients with:

Rheumatoid arthritis

Lupus

or another inflammatory arthropathy may require:

Disease-modifying therapy

rather than isolated treatment of the:

Tendon sheath.

Follow-Up

Patients should be reassessed according to:

Severity

Location

and

Treatment response.

Typical Monitoring

Nonoperative cases may be reviewed at approximately:

4–6 week intervals.

Examination During Follow-Up

Follow-up should evaluate:

Pain

Swelling

Range of motion

Tendon function

and return to:

Normal activity.

Prognosis

Most uncomplicated cases respond successfully to:

Nonoperative treatment.

Recurrent Disease

Some tendon regions have a greater tendency toward recurrence, particularly the:

Posterior tibial tendon

and

Achilles tendon.

Chronic Tenosynovitis

Longstanding disease may be more difficult to resolve because of:

Fibrosis

Tendon degeneration

and persistent:

Mechanical irritation.

Infectious Prognosis

Outcome in septic tenosynovitis depends heavily on:

Early recognition

and

Prompt treatment.

Delayed care increases the risk of permanent:

Tendon and joint dysfunction.

Complications

The principal complication of noninfectious disease is:

Persistence or recurrence of symptoms.

Tendon Degeneration

Chronic tenosynovitis may contribute to:

Tendon weakening

and occasionally:

Tendon rupture.

Adhesions

Inflammation or surgery can lead to:

Tendon adhesions

and impaired:

Tendon gliding.

Stiffness

Pain and prolonged immobilization can result in:

Joint stiffness

and reduced:

Range of motion.

Infection Complications

Untreated septic tenosynovitis may cause:

Abscess formation

Tendon necrosis

Joint infection

Osteomyelitis

or permanent:

Functional loss.

Patient Monitoring

Patients should be monitored for:

Resolution of pain

Improved tendon excursion

Restoration of range of motion

and recurrence of:

Swelling or triggering.

Key Principle

Tenosynovitis is a disorder of the synovial tendon sheath that may result from mechanical overuse, systemic inflammatory disease, infection, or an idiopathic process.

Typical findings include:

Pain and tenderness along the tendon, swelling, crepitus, and pain with use.

Most noninfectious cases improve with:

Relative rest, temporary splinting, NSAIDs, activity modification, and therapy.

Selected conditions such as:

de Quervain tenosynovitis and trigger finger

may respond to:

Corticosteroid injection.

Persistent mechanical disease may require:

Surgical sheath release or synovectomy, whereas:

Septic flexor tenosynovitis is an urgent condition requiring antibiotics and often operative irrigation and decompression.