Tenosynovitis 

  • Author: Jeffrey G Norvell, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Dec 11, 2009
 

Background

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.

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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.

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Epidemiology

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]

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Proceed to Clinical Presentation
 
 
Contributor Information and Disclosures
Author

Jeffrey G Norvell, MD  Clinical Assistant Professor of Emergency Medicine, University of Kansas School of Medicine

Jeffrey G Norvell, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Mark Steele, MD  Associate Dean for Truman Medical Center Programs, Professor, Department of Emergency Medicine, University of Missouri-Kansas City

Mark Steele, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard S Krause, MD  Senior Faculty, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine

Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Gino A Farina, MD, FACEP, FAAEM  Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Program Director, Department of Emergency Medicine, Long Island Jewish Medical Center

Gino A Farina, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. [Guideline] Work Loss Data Institute. Forearm, wrist, & hand (acute & chronic), not including carpal tunnel syndrome. Corpus Christi (TX): Work Loss Data Institute; 2008. [Full Text].

  2. Pang HN, Teoh LC, Yam AK, Lee JY, Puhaindran ME, Tan AB. Factors affecting the prognosis of pyogenic flexor tenosynovitis. J Bone Joint Surg Am. Aug 2007;89(8):1742-8. [Medline].

  3. Richie CA 3rd, Briner WW Jr. Corticosteroid injection for treatment of de Quervain's tenosynovitis: a pooled quantitative literature evaluation. J Am Board Fam Pract. Mar-Apr 2003;16(2):102-6. [Medline].

  4. Sawaizumi T, Nanno M, Ito H. De Quervain's disease: efficacy of intra-sheath triamcinolone injection. Int Orthop. Apr 2007;31(2):265-8. [Medline].

  5. Lane LB, Boretz RS, Stuchin SA. Treatment of de Quervain's disease:role of conservative management. J Hand Surg [Br]. Jun 2001;26(3):258-60. [Medline].

  6. Chambers RG Jr. Corticosteroid injections for trigger finger. Am Fam Physician. Sep 1 2009;80(5):454. [Medline].

  7. [Best Evidence] Peters-Veluthamaningal C, Winters JC, Groenier KH, Meyboom-de Jong B. Corticosteroid injections effective for trigger finger in adults in general practice: a double-blinded randomized placebo controlled trial. Ann Rheum Dis. Jan 7 2008;[Medline].

  8. Biundo JJ Jr, Mipro RC Jr, Fahey P. Sports-related and other soft-tissue injuries, tendinitis, bursitis, and occupation-related syndromes. Curr Opin Rheumatol. Mar 1997;9(2):151-4. [Medline].

  9. Brook I. Management of human and animal bite wounds: an overview. Adv Skin Wound Care. May 2005;18(4):197-203. [Medline].

  10. Goldenberg DL. Gonococcal arthritis. In: McCarty DJ, ed. Arthritis and Allied Conditions: A Textbook of Rheumatology. 11th ed. Philadelphia, Pa: Lea and Febiger; 1989.

  11. Graham JB, Hulkower SD, Bosworth M, White EL, Gauer R. Clinical inquiries. Are steroid injections effective for tenosynovitis of the hand?. J Fam Pract. Dec 2007;56(12):1045-7. [Medline].

  12. Jirarattanaphochai K, Saengnipanthkul S, Vipulakorn K. Treatment of de Quervain disease with triamcinolone injection with or without Nimesulide. J Bone Joint Surg Am. 2004;86-A:2700-06. [Medline].

  13. Krieger LE, Schnall SB, Holtom PD, Costigan W. Acute gonococcal flexor tenosynovitis. Orthopedics. Jul 1997;20(7):649-50. [Medline].

  14. Lewis RC Jr. Infections of the hand. Emerg Med Clin North Am. May 1985;3(2):263-74. [Medline].

  15. Moore JS. De Quervain's tenosynovitis. Stenosing tenosynovitis of the first dorsal compartment. J Occup Environ Med. Oct 1997;39(10):990-1002. [Medline].

  16. Nimigan AS, Ross DC, Gan BS. Steroid injections in the management of trigger fingers. Am J Phys Med Rehabil. Jan 2006;85(1):36-43. [Medline].

  17. Ryzewicz M, Wolf JM. Trigger digits: principles, management, and complications. J Hand Surg [Am]. Jan 2006;31(1):135-46. [Medline].

  18. Schaefer RA, Enzenauer RJ, Pruitt A, Corpe RS. Acute gonococcal flexor tenosynovitis in an adolescent male with pharyngitis. A case report and literature review. Clin Orthop. Aug 1992;(281):212-5. [Medline].

  19. Scopelitis E, Martinez-Osuna P. Gonococcal arthritis. Rheum Dis Clin North Am. May 1993;19(2):363-77. [Medline].

  20. Shirtliff ME, Mader JT. Acute septic arthritis. Clin Microbiol Rev. Oct 2002;15(4):527-44. [Medline].

  21. Watson FM Jr. Nonarthritic inflammatory problems of the hand and wrist. Emerg Med Clin North Am. May 1985;3(2):275-82. [Medline].

 
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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 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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