eMedicine Specialties > Emergency Medicine > Rheumatology
Tenosynovitis: Treatment & Medication
Updated: Mar 31, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Emergency Department Care
- de Quervain tenosynovitis
- Prescribe rest, nonsteroidal anti-inflammatory agents, and thumb spica wrist splint for those with minimal symptoms.
- Peritendinous lidocaine/corticosteroid injection is considered by many to be the initial treatment of choice for de Quervain tenosynovitis. One review of the literature showed corticosteroid treatment to have a cure rate greater than 80% and concluded that corticosteroid injection is safe.2
- A study published in 2007 examined triamcinolone injections for de Quervain tenosynovitis and achieved an efficacy rate of 89%.3 In this study, patients could receive a maximum of 3 injections separated 2 weeks apart. A favorable result was measured by a questionnaire indicating no disruption in daily life.
- One retrospective review concluded that, in patients with more than minimal symptoms in de Quervain tenosynovitis, steroids are superior to nonsteroidal anti-inflammatory agents and splinting.4
- Surgical therapy is an option if conservative management fails.
- Volar flexor tenosynovitis (ie, trigger finger)
- Activity modification (ie, avoiding activities that cause triggering) and nonsteroidal anti-inflammatory drugs are used.
- Peritendinous lidocaine/corticosteroid injection is the treatment of choice for volar flexor tenosynovitis (ie, trigger finger). A recent randomized placebo-controlled trial compared corticosteroid injections with placebo.5 In this study, subjects treated with corticosteroid injection showed a statistically significant reduction in severity of pain, frequency of triggering, and perceived patient improvement as compared with placebo. The short-term effects were maintained during the 12-month follow-up phase.
- Splinting is another treatment modality that has been studied. This is appropriate for patients who do not want to have a steroid injection.
- Consider surgical tendon release if injection fails. Surgical release for trigger finger has success rates greater than 90%.
- Gonococcal tenosynovitis
- Admit to hospital with IV or intramuscular (IM) antibiotics (eg, ceftriaxone, spectinomycin)
- Surgical drainage may be indicated if antibiotic therapy does not significantly improve condition within 48 hours.
- Nongonococcal infectious tenosynovitis
- If the diagnosis is equivocal, admission to a hand specialist (eg, plastic surgery, orthopedics), elevation, and broad-spectrum antibiotics to include staphylococcal and/or streptococcal bacterial coverage are necessary.
- Add anaerobic coverage if anaerobic infection is likely (ie, with cat or human bites). If the diagnosis of tenosynovitis is definite, refer to hand specialist for urgent surgical incision and drainage.
Consultations
- Primary care or hand specialty outpatient referral for follow-up care of de Quervain tenosynovitis and volar flexor tenosynovitis
- Emergent medical or hand specialty consultation for suspected GC tenosynovitis for hospital admission and IV antibiotics
- Emergent hand specialty consultation for nongonococcal infectious tenosynovitis for hospital admission, IV antibiotics, and possible surgical drainage
Medication
The goals of therapy are to reduce pain and eradicate infection.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Most commonly used for relief of mild to moderate pain. Although effects of NSAIDs in treatment of pain tend to be patient specific, ibuprofen usually is the DOC for initial therapy. Other options include fenoprofen, flurbiprofen, mefenamic acid, ketoprofen, indomethacin, and piroxicam. NSAIDs are used primarily for de Quervain and volar flexor tenosynovitis.
Ibuprofen (Motrin, Advil, Ibuprin, Nuprin)
Usually DOC for treatment of mild to moderate pain if no contraindications exist.
Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which results in inhibition of prostaglandin synthesis.
Adult
400 mg PO q4-6h, 600 mg PO q6h, or 800 mg PO q8h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 10-70 mg/kg/d PO divided tid/qid; start at lower end of dosing range and titrate upward; not to exceed 2.4 g/d
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and possibly toxicity of NSAIDs; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Anaprox, Naprelan, Naprosyn, Aleve)
Used for relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which results in prostaglandin synthesis.
Adult
250 mg PO q6-8h or 500 mg bid; not to exceed 1.25 g/d; may increase to 1.5 g/d for limited periods
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and possibly toxicity of NSAIDs; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Ceftriaxone (Rocephin)
Third-generation cephalosporin that has broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms.
By binding to 1 or more of the penicillin-binding proteins, it arrests bacterial cell wall synthesis and inhibits bacterial growth.
Used because of increasing prevalence of penicillinase producing N gonorrhoeae.
Adult
1-2 g IV/IM qd or divided bid; not to exceed 4 g/d
Pediatric
<7 days: Not established
>7 days: 25-50 mg/kg/d IV; not to exceed 125 mg/d
Infants and children: 50-75 mg/kg/d IV divided q12h; not to exceed 2 g/d
Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in breastfeeding women and those with allergy to penicillin
Spectinomycin (Trobicin)
Inhibits protein synthesis in bacterial cells. Site of action is 30S ribosomal subunit; structurally different from related aminoglycosides.
Used as alternative antimicrobial in treatment of urethral, endocervical, or rectal GC infections in patients who cannot take cephalosporins or fluoroquinolones.
Can be administered to pregnant women who are allergic to cephalosporins.
Adult
2 g IM q12h
Pediatric
<45 kg and cannot tolerate ceftriaxone: 40 mg/kg/d IM divided q12h or once; not to exceed 2 g/dose
>45 kg and cannot tolerate ceftriaxone: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Benzyl alcohol used as diluent associated with fatal gasping syndrome in infants; antibiotics may mask or delay symptoms of incubating syphilis; perform a serologic test for syphilis in all patients with gonorrhea at time of diagnosis followed by additional test after 3 mo; monitor clinical effectiveness to detect resistance by N gonorrhoeae
Ciprofloxacin (Cipro)
Bactericidal antibiotic that inhibits bacterial DNA synthesis and consequently growth by inhibiting DNA-gyrase in susceptible organisms.
Duration of treatment depends upon severity of infection. Continue treatment for at least 2 d after signs and symptoms of infection have disappeared. Usual treatment duration is 7-14 d.
Adult
250-500 mg PO bid for 7-14 d
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Ampicillin and sulbactam (Unasyn)
Drug combination that uses beta-lactamase inhibitor with ampicillin; covers skin, enteric flora, and anaerobes.
Used for treatment of nongonococcal infectious tenosynovitis.
Coverage includes Staphylococcus species, Streptococcus species, and anaerobes.
Adult
1.5 (1 g ampicillin + 0.5 g sulbactam) to 3 g (2 g ampicillin + 1 g sulbactam) IV/IM q6-8h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Pediatric
<3 months: Not established
3 months to 12 years: Ampicillin 100-200 mg/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Cefazolin (Ancef)
First-generation semisynthetic cephalosporin, which by binding to 1 or more of the penicillin-binding proteins arrests bacterial cell wall synthesis and inhibits bacterial growth; primarily active against skin flora, including S aureus. Typically, used alone for skin and skin-structure coverage.
Total daily dosages are the same for IV and IM administrations.
Used for suspected staphylococcal and/or streptococcal tenosynovitis (anaerobes not suspected).
Adult
250 mg to 2 g IV/IM q6-12h depending on severity of infection; not to exceed 12 g/d
Pediatric
25-100 mg/kg/d IV/IM divided q6-8h depending on severity of infection; not to exceed 6 g/d
Probenecid prolongs effect of cefazolin; coadministration with aminoglycosides may increase renal toxicity; may yield false-positive urine-dip test for glucose
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy
Corticosteroids
These agents have both anti-inflammatory (glucocorticoid) and salt-retaining (mineralocorticoid) properties. Glucocorticoids have profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.
Dexamethasone acetate (Decadron, AK-Dex, Alba-Dex, Dexone)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability. Dosage varies with degree of inflammation and size of affected area.
Adult
4-16 mg intralesionally (0.5-1) mL mixed with equal or double volume of 1% local anesthetic (ie, lidocaine)
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; decreases effect of salicylates and vaccines used for immunization
Documented hypersensitivity; active bacterial or fungal infection
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, PUD, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use
Methylprednisolone acetate (Solu-Medrol, Depo-Medrol, Medrol)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Use 0.5-1 mL (40 mg/mL) mixed with equal or double volume of 1% local anesthetic (ie, lidocaine).
Dosage varies with degree of inflammation and size of affected area.
Adult
Tendon sheath inflammation: 4-30 mg intralesionally
Pediatric
Not established
Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels of methylprednisolone; phenobarbital, phenytoin, and rifampin may decrease levels of methylprednisolone (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hyperglycemia, edema, osteonecrosis, PUD, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use
Hydrocortisone acetate (Solu-Cortef, Cortef)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Use 0.5-1 mL (25 or 50 mg/mL) mixed with equal or double volume of 1% local anesthetic (ie, lidocaine).
Dosage varies with degree of inflammation and size of affected area.
Adult
5-12.5 mg intralesionally
Pediatric
Not established
Corticosteroid clearance may decrease with estrogens; may increase digitalis toxicity secondary to hypokalemia
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hyperthyroidism, osteoporosis, peptic ulcer, cirrhosis, nonspecific ulcerative colitis, diabetes, and myasthenia gravis
More on Tenosynovitis |
| Overview: Tenosynovitis |
| Differential Diagnoses & Workup: Tenosynovitis |
 Treatment & Medication: Tenosynovitis |
| Follow-up: Tenosynovitis |
| References |
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References
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].
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].
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].
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].
[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].
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].
Brook I. Management of human and animal bite wounds: an overview. Adv Skin Wound Care. May 2005;18(4):197-203. [Medline].
Goldenberg DL. Gonococcal arthritis. In: McCarty DJ, ed. Arthritis and Allied Conditions: A Textbook of Rheumatology. 11th ed. Philadelphia, Pa: Lea and Febiger; 1989.
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].
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].
Krieger LE, Schnall SB, Holtom PD, Costigan W. Acute gonococcal flexor tenosynovitis. Orthopedics. Jul 1997;20(7):649-50. [Medline].
Lewis RC Jr. Infections of the hand. Emerg Med Clin North Am. May 1985;3(2):263-74. [Medline].
Moore JS. De Quervain's tenosynovitis. Stenosing tenosynovitis of the first dorsal compartment. J Occup Environ Med. Oct 1997;39(10):990-1002. [Medline].
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].
Ryzewicz M, Wolf JM. Trigger digits: principles, management, and complications. J Hand Surg [Am]. Jan 2006;31(1):135-46. [Medline].
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].
Scopelitis E, Martinez-Osuna P. Gonococcal arthritis. Rheum Dis Clin North Am. May 1993;19(2):363-77. [Medline].
Shirtliff ME, Mader JT. Acute septic arthritis. Clin Microbiol Rev. Oct 2002;15(4):527-44. [Medline].
Watson FM Jr. Nonarthritic inflammatory problems of the hand and wrist. Emerg Med Clin North Am. May 1985;3(2):275-82. [Medline].
Further Reading
Keywords
de Quervain tenosynovitis of the wrist, abductor pollicis longus tendons, extensor pollicis brevis tendons, volar flexor tenosynovitis, stenosing tenosynovitis, trigger finger, gonococcal tenosynovitis, GC tenosynovitis, Finkelstein test, nongonococcal infectious tenosynovitis, suppurative tenosynovitis, pyogenic flexor tenosynovitis, cardinal signs of Kanavel, Neisseria gonorrhoeae, Staphylococcus aureus, Streptococcus species, Pasteurellamultocida, cat bites, Eikenella corrodens, human bites, Mycobacterium species, diabetes mellitus, intravenous drug abuse, IV drug abuse, arteriosclerosis obliterans
