Tenosynovitis

Tenosynovitis

 involves inflammation of the tendon and tendon sheath. Examples of tenosynovitis include de Quervain tenosynovitis of the wrist (ie, abductor pollicis longus and extensor pollicis brevis tendons), volar flexor tenosynovitis (ie, trigger finger), pyogenic flexor tenosynovitis, which can be from gonococcal infections and other infectious etiologies.

Pathophysiology

Flexor tendons of the hand run in tight fibroosseous tunnels. Visceral and parietal layers of synovium lubricate and nourish the tendons. These layers are usually collapsed unless infection, which follows the path of least resistance along the tendon sheaths or inflammation, is present.
Infection can be introduced directly into the tendon sheaths through a skin wound (most often) or via hematogenous spread, as occurs with gonococcal tenosynovitis. Gonococcal infection originates as a mucosal infection of the genital tract, rectum, or pharynx. Dissemination occurs in approximately 1-3% of patients with mucosal infection. Approximately two thirds of patients with disseminated gonococcal infection develop tenosynovitis.
A history of recent trauma to the involved area is not uncommon and is believed to be a predisposing factor for the development of pyogenic flexor tenosynovitis.¹ Overuse leads to inflammation in de Quervain tenosynovitis. Etiology of volar flexor tenosynovitis is unknown.

Mortality/Morbidity

One complication of infectious tenosynovitis is a loss of active range of motion. A less frequent complication of infectious tenosynovitis is digit amputation, which occurs most commonly in very advanced cases. Pang et al conducted a review of 75 patients with pyogenic flexor tenosynovitis and found that the following risk factors were associated with poorer outcomes: (1) age older than 45 years; (2) presence of diabetes mellitus, renal failure, or peripheral vascular disease; (3) ischemic changes at the time of presentation; (4) subcutaneous purulence; and (5) polymicrobial infection at the time of surgery.²

Clinical

History

• de Quervain tenosynovitis
  • Patients have a history of repetitive pinching motion of the thumb and fingers (eg, assembly line work, driving in screws, weeding).
  • Pain in the radial aspect of the wrist becomes worse with activity and better with rest. Onset of pain is typically gradual in nature with no history of acute trauma. The affected area is shown in the image below.
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    The first dorsal compartment of the wrist includes the tendon sheath that encloses the abductor pollicis longus and the extensor pollicis brevis tendons at the lateral border of the anatomic snuffbox.

    

    The first dorsal compartment of the wrist includes the tendon sheath that encloses the abductor pollicis longus and the extensor pollicis brevis tendons at the lateral border of the anatomic snuffbox.

  • Most common in middle-aged women
• Volar flexor tenosynovitis (ie, trigger finger)
  • This type of tenosynovitis most commonly affects the thumb or ring finger.
  • Most common in middle-aged women
  • More common in patients with diabetes
  • Locking of involved finger in flexion is followed by sudden release (hence the name trigger finger); hand pain radiates to fingers. In more severe cases, the finger may require passive manipulation to regain extension.
• Gonococcal tenosynovitis
  • This type of inflammation most commonly affects teenagers and young adults; gonococcal tenosynovitis is more common in women, especially during pregnancy or after menstruation, when dissemination of gonorrhea is more likely to occur.
  • Interval from sexual exposure to onset of symptoms of dissemination can vary from 1 day to several weeks.
  • Vaginal or penile discharges are usually absent; fever, chills, malaise, and polyarthralgias are common.
  • Most common sites affected are the dorsum of the wrist, hand, and ankle.
• Nongonococcal infectious tenosynovitis
  • A puncture wound, dry cracked skin, laceration, bite, or high-pressure injection injury (eg, paint, grease gun) may be present.
  • Frequently, no obvious portal of injury is present.
  • Pain and swelling occur along affected tendon; flexor hand tendons are most commonly involved.

Physical

• de Quervain tenosynovitis
  • Pain occurs on palpation along the radial aspect of the wrist.
  • Pain occurs with passive range of motion of the thumb.
  • Pain occurs with ulnar deviation of the wrist with the thumb cupped in a closed fist; this is termed the Finkelstein test and is shown in the image below.
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    The Finkelstein test is performed by having the patient make a fist with the thumb inside the fingers. The clinician then applies ulnar deviation of the wrist to reproduce the presenting symptoms of dorsolateral wrist pain.

    

    The Finkelstein test is performed by having the patient make a fist with the thumb inside the fingers. The clinician then applies ulnar deviation of the wrist to reproduce the presenting symptoms of dorsolateral wrist pain.

• Volar flexor tenosynovitis (ie, trigger finger)
  • Tenderness is present at the proximal end of the tendon sheath, in the distal palm (just proximal to metacarpal head).
  • Palpable tendon thickening and nodularity may be present.
  • Crepitation and catching of the tendon may be appreciated when the finger is flexed.
• Gonococcal tenosynovitis
  • Erythema, tenderness to palpation, and painful range of motion of the involved tendon(s) are present.
  • Fever is common.
  • Dermatitis is also common (occurs in approximately two thirds of disseminated gonococcal) and is characterized by hemorrhagic macules or papules on the distal extremities or trunk.
• Nongonococcal infectious tenosynovitis
  • Tenderness, erythema, and painful range of motion of the involved tendon(s) are present.
  • Cardinal signs of Kanavel include the following: (1) fusiform swelling of the finger (swelling along the whole digit), (2) flexed position of the finger, (3) severe pain with passive extension of the finger, and (4) tenderness and swelling along and limited to the flexor tendon sheath.

Causes

• de Quervain tenosynovitis: Overuse leads to thickening of the extensor retinaculum of the first dorsal compartment and narrowing of the fibroosseous canal.
• Volar flexor tenosynovitis (ie, trigger finger): Overuse is thought to be the most common cause, but multiple etiologies have been identified. The triggering phenomenon is thought to be caused by hypertrophy of the first annular pulley.
• Gonococcal tenosynovitis: Neisseria gonorrhoeae is a cause.
• Nongonococcal infectious tenosynovitis
  • Staphylococcus aureus and Streptococcus species are the most common etiologic agents, but infection is frequently mixed (aerobic and anaerobic).
  • Pasteurella multocida is common with cat bites; Eikenella corrodens occurs with human bites. However, human and animal bites may have a mixture of aerobic and anaerobic flora.
  • Predisposing factors include diabetes mellitus, intravenous (IV) drug abuse, debility, and arteriosclerosis obliterans.
  • Mycobacterium species can also cause tenosynovitis, particularly in immunocompromised patients.