Tenosynovitis Treatment & Management

  • Author: Jeffrey G Norvell, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Mar 9, 2012
 

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.[3]
    • A study examined triamcinolone injections for de Quervain tenosynovitis and achieved an efficacy rate of 89%.[4] 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.[5]
    • Surgical therapy is an option if conservative management fails.[6]
  • 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).[7] A randomized placebo-controlled trial compared corticosteroid injections with placebo.[8] 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 intravenous (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.
Next

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 gonococcal tenosynovitis for hospital admission and IV antibiotics
  • Emergent hand specialty consultation for nongonococcal infectious tenosynovitis for hospital admission, IV antibiotics, and possible surgical drainage
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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, MD, Professor, Department of Emergency Medicine, Chief Medical Officer, Truman Medical Center, University of Missouri-Kansas City School of Medicine

Mark Steele 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 Clinical Faculty/Clinical Assistant Professor, Department of Emergency Medicine, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

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  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape 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  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

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

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous editor, Charles V Pollack Jr, MD, to the development and writing of this article.

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. Abrisham SJ, Karbasi MH, Zare J, Behnamfar Z, Tafti AD, Shishesaz B. De qeurvian tenosynovitis: clinical outcomes of surgical treatment with longitudinal and transverse incision. Oman Med J. Mar 2011;26(2):91-3. [Medline]. [Full Text].

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

  8. [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].

  9. 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].

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

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

  12. 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].

  13. 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].

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

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

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

  17. 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].

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

  19. 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].

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

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

  22. 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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