Tenosynovitis Clinical Presentation

Updated: Oct 05, 2015
  • Author: Mark R Foster, MD, PhD, FACS; Chief Editor: Harris Gellman, MD  more...
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Presentation

History

Gonococcal tenosynovitis

This type of tenosynovitis most commonly affects teenagers and young adults; it is more common in women, especially during pregnancy or after menstruation, when dissemination of gonorrhea is more likely to occur. Features of gonococcal tenosynovitis include the following:

  • The interval from sexual exposure to onset of symptoms of dissemination can range from 1 day to several weeks
  • Vaginal or penile discharges are usually absent; fever, chills, malaise, and polyarthralgias are common
  • The most commonly affected sites are the dorsum of the wrist, hand, and ankle

Nongonococcal infectious tenosynovitis

Features of this form of tenosynovitis include the following:

  • Dry, cracked skin or a puncture wound, 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 the affected tendon; flexor hand tendons are most commonly involved

Inflammatory tenosynovitis

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. This condition is most common in middle-aged women. The affected area is shown in the image below.

The first dorsal compartment of the wrist includes 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.

Volar flexor tenosynovitis

The features of this condition (also known as trigger finger) include the following:

  • Most commonly affects the thumb or ring finger
  • Most common in middle-aged women
  • More common in patients with diabetes

Locking of the 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.

Next:

Physical Examination

Infectious tenosynovitis

Patients with infectious flexor tenosynovitis (FT) can present at any time after a penetrating injury, with complaints of pain, redness, and fever. Physical examination reveals Kanavel signs of flexor tendon sheath infection, which are as follows:

  • Finger held in slight flexion
  • Fusiform swelling
  • Tenderness along the flexor tendon sheath
  • Pain with passive extension of the digit

However, Kanavel signs may be absent in patients with the following:

  • Recently administered antibiotics
  • Early manifestations of the condition
  • Immunocompromised state
  • Chronic infections

Additionally, patients with immunocompromising conditions may present with a rather innocuous injury, such as a small puncture wound from a foreign body. Presenting symptoms may be vague in certain indolent infectious states.

Gonococcal tenosynovitis

Clinical features include the following:

  • Erythema, tenderness to palpation, and painful range of motion (ROM) of the involved tendon(s) are present
  • Fever is common
  • Dermatitis is also common (occurs in approximately two thirds of disseminated gonococcal); it is characterized by hemorrhagic macules or papules on the distal extremities or trunk

Inflammatory flexor tenosynovitis

Inflammatory FT usually is the result of an underlying disease process. Presentation is indolent but progressive if therapy is not initiated. Similar findings to those found in infectious FT eventually present. In inflammatory FT, swelling is the most common initial finding. The hallmark of inflammatory FT is a difference in active, versus passive, flexion. As the tissue expands and impingement occurs, pain and restricted motion ensue. Delayed presentations can have the appearance of fulminant FT with all Kanavel signs or may involve tendon rupture if the patient delays seeking treatment long enough.

Volar flexor tenosynovitis

Clinical features of this condition (also known as trigger finger) include the following:

  • Tenderness is present at the proximal end of the tendon sheath, in the distal palm (just proximal to the metacarpal head)
  • Palpable tendon thickening and nodularity may be present
  • Crepitation and catching of the tendon may be appreciated when the finger is flexed

De Quervain tenosynovitis

Clinical features include the following:

  • Pain occurs on palpation along the radial aspect of the wrist
  • Pain occurs with passive ROM 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 (see the image below)
The Finkelstein test is performed by having the pa 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.
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