Tenosynovitis Treatment & Management

Nonoperative management

Naturally, treatment for tenosynovitis will depend entirely on the etiology of inflammation. Nonoperative management is frequently pursued for nonsuppurative flexor tenosynovitis, but surgical intervention may be indicated for chronic conditions. 

Infectious flexor tenosynovitis, however, remains an orthopedic emergency, and there is a very narrow indication for trialing nonoperative management. Accordingly, many surgeons recommend early operative drainage in all cases. Nevertheless, the current literature demonstrates that medical treatment can be pursued for early, uncomplicated infections. Prompt improvement of symptoms and physical findings must follow within the ensuing 12 hours; otherwise, surgical intervention is necessary.

Surgical management

In instances of delayed presentation or progressive infection, prompt operative exploration and irrigation of the tendon sheath are warranted. Several approaches to access the flexor tendon sheath have been described. In general, these either provide wide exposure of the sheath or attempt to access the space via minimally invasive incisions distally and proximally. For Michon stage I (accumulation of exudative fluid in tendon sheath) and stage II (purulent fluid, granulomatous synovium) flexor tenosynovitis, either approach can be used. Strong evidence and widespread agreement support wide exposure of Michon stage III infections (necrosis of the tendon, pulleys, or tendon sheath).

Dailiana et al, in a retrospective study of 41 patients with purulent flexor tenosynovitis, found that the best functional outcome associated with this condition resulted from early diagnosis, drainage through small incisions, and continuous postoperative irrigation; worse outcomes resulted in cases of delayed treatment and infections with specific pathogens. ^[46]  Staphylococcus aureus was detected in most cases. Some surgeons still advocate radical tenosynovectomy for Mycobacterium infections, whereas others prefer partial tenosynovectomy with a multiple antibiotic regimen and close observation.

Infectious tenosynovitis

Prompt medical management of acute infectious flexor tenosynovitis (ie, pyogenic flexor tenosynovitis [PFT]) may preclude the need for immediate surgical intervention. Nonoperative treatment for infectious flexor tenosynovitis includes the following:

• If possible, aspiration of synovial fluid from the flexor sheath for gram stain and culture through noncellulitic skin
• Broad-spectrum intravenous (IV) antibiotics initially, culture-directed narrowing with resolution of infection
• Elevation of the affected hand
• Splinting in “position of safety”
• Rehabilitation, inlcuding digital range-of-motion (ROM) exercises and edema control, once infection is under control

If the diagnosis is equivocal, consultation with a hand specialist (eg, from plastic surgery or orthopedic surgery) and the use of elevation and broad-spectrum antibiotics that include staphylococcal coverage, streptococcal coverage, or both are necessary. Addition of anaerobic coverage is warranted if anaerobic infection is likely (eg, in cases of bite injury). Empiric antibiotics for penetrating trauma and infection should be guided by hospital antibiograms.

For immunocompromised or diabetic patients, early surgical intervention is warranted. If medical treatment alone is attempted, then inpatient observation for at least 48 hours is indicated. Surgical drainage is necessary if no obvious improvement has occurred within 12-24 hours.

Gonococcal tenosynovitis

The patient should be admitted to the hospital with IV or intramuscular (IM) antibiotics (eg, ceftriaxone or spectinomycin). Surgical drainage may be indicated if antibiotic therapy does not significantly improve the patient’s condition within 48 hours.

Idiopathic or stenosing tenosynovitis

The mainstay of therapy for tenosynovitis caused by stenosing conditions is cessation of the insult through modification of activity. Therapy also includes the following:

• Icing and elevation of the affected area
• Administration of a nonsteroidal anti-inflammatory drug (NSAID) if tolerated by the patient
• Consideration of a short course of oral steroids
• Administration of flexor tendon sheath or carpal tunnel corticosteroid injections to decrease pain and the inflammatory response
• Splinting - If utilized, splinting should be limited in area to a pain-free ROM
• Rehabilitation - Slow rehabilitation prevents reinitiation of the inflammatory phase

Caution must be exercised with corticosteroid injections, because they are detrimental if done directly into the tendon or ligament. Multiple injections also can weaken the tendon and lead to rupture in patients with diabetes or inflammatory arthritis (eg, rheumatoid arthritis [RA]). Therefore, corticosteroid injections should be used with particular care in patients with these conditions. Also, the use of injectable or oral steroids is contraindicated if infectious flexor tenosynovitis has not been completely ruled out.

De Quervain tenosynovitis

For patients with minimal symptoms rest, NSAIDs, and a thumb spica wrist splint should be prescribed. ^[47]

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 of greater than 80% and concluded that corticosteroid injection is safe. ^[48] Surgical therapy is an option if conservative management fails. ^[49]

A study examined injections of triamcinolone for de Quervain tenosynovitis and found an 89% efficacy rate for the drug. ^[50] In this report, patients could receive a maximum of three injections 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 NSAIDs and splinting. ^[51]

Trigger digits

Peritendinous lidocaine-corticosteroid injection is the initial treatment of choice for trigger finger. ^[52] In a randomized trial, patients with this condition who were treated with corticosteroid injection showed a greater reduction in pain severity and frequency of triggering than did patients treated with placebo. The short-term effects were maintained during a 12-month follow-up phase. ^[53]

In a double-blind randomized controlled study from Taiwan that compared ultrasound-guided injection of hyaluronic acid with steroid injection in 36 patients with trigger finger (39 digits), Liu et al found that the former treatment yielded promising results for the treatment of this condition, though optimal regimens remained to be defined. ^[54]

Treatment also includes activity modification (ie, avoidance of activities that cause triggering) and NSAIDs. Splinting is another treatment modality that has been studied. This is appropriate for patients who do not want to have a steroid injection.

Surgical tendon release should be considered if injection fails. Surgical release for trigger finger has success rates higher than 90%.

Inflammatory flexor tenosynovitis

Nonoperative management is the primary treatment for inflammatory tenosynovitis. In patients refractory to at least 3-6 months of good medical management or in patients with tendon ruptures, flexor tenosynovectomy should be performed.

Treatment for rheumatoid inflammatory flexor tenosynovitis includes ice, NSAIDs, rest, splinting, hydroxychloroquine, gold, penicillamine, and methotrexate. Persistent cases may require oral steroid treatment. For acute flares of flexor tenosynovitis in patients with RA, corticosteroid injections may provide prompt relief. Injections should be limited so as to avoid tendon rupture. ^[55]

Infectious tenosynovitis

Several drainage techniques can be used in PFT. The choice of method is based on the extent of the infection. The Michon classification scheme can be a helpful guide in surgical intervention (see Table 2 below).

Table 2. Treatment of Infectious Tenosynovitis According to Michon Stage (Open Table in a new window)

Most current recommendations for stage I and stage II infections advocate proximal and distal incisions for adequate drainage and irrigation.

The proximal incision is made over the A1 pulley. If the radial or ulnar bursa is the suggested point of tenosynovitis, the incision should be made just proximal to the transverse carpal ligament. In the digit, either a standard Brunner incision or a midaxial incision may be utilized.

The distal incision is made over the region of the A5 pulley. If the midaxial approach is taken, the incision should be dorsal to the neurovascular bundle. A Brunner incision allows better initial exposure but may complicate closure or coverage if skin necrosis ensues and is more likely to interfere with therapy postoperatively.

A 16-gauge polyethylene catheter or a 3.5- to 5-French feeding tube then is inserted into the tendon sheath through the proximal incision. The sheath is copiously irrigated with a minimum of 500 mL of normal saline. Excessive fluid extravasation into the digit must be avoided because it can result in necrosis of the digit.

The catheter can be loosely sewn in or simply removed after irrigation. A small drain is placed in the distal incision, and the wounds are left open. A splint is applied, the hand is elevated, and the appropriate empiric antibiotic coverage is started while the clinician awaits culture results.

Some clinicians prefer the continuous irrigation technique over a period of 24-48 hours. The catheter is sewn in place, and a small drain is secured at the distal incision site. Either continuous irrigation with sterile saline at a rate of 25 mL/hr or intermittent irrigation every 2-4 hours with 25-50 mL of sterile saline may be performed; the two techniques are equally effective. ^{[56, 57, 58]}

Indications for open tendon sheath débridement include the following:

• Stage III infections
• Chronic infections
• Infections caused by atypical mycobacteria

To expose the tendon sheath, a volar zigzag Brunner incision or a longitudinal midaxial incision is made. The midaxial incision is preferred because of postoperative coverage concerns. The thumb and small fingers are approached from the radial side; the other digits are approached from the ulnar side. The incision begins distally at the level of the A5 pulley, or just distal to the distal flexion crease, and is extended proximally to the web space. The incision is kept dorsal to the neurovascular bundle.

For extensive infections, the sheath may be opened at all of the cruciform pulleys with preservation of the anular pulleys, especially the A2 and A4 pulleys. If the small finger or thumb is involved and there is evidence of proximal involvement, an additional incision, proximal to the transverse carpal ligament, is made to ensure adequate drainage of the radial and ulnar bursae.

The sheath is copiously irrigated, and the wounds are left open with drains in place. Empiric antibiotics are started. The hand is dressed and splinted, and the wounds are reevaluated after 48 hours. If the infection has abated, the drains are removed and postoperative therapy is initiated. If the infection is not controlled, repeat irrigation and débridement are necessary.

For Mycobacterium infection, extensive tenosynovectomy may be necessary, depending on the chronicity of infection.

Idiopathic or stenosing tenosynovitis

Release of the A1 pulley may be performed in cases not amenable to steroid injection. Percutaneous approaches have been described, though these place the neurovascular bundle at risk in that the bundle cannot be directly visualized during transection of the pulley. In an open approach, a small incision is made at the metacarpophalangeal (MCP) crease palmarly. Dissection proceeds down to the level of the A1 pulley. Neurovascular bundles are retracted away if encountered, and the A1 pulley is completely sectioned. The digit should be passively and actively flexed to ensure full release.

Inflammatory tenosynovitis

For inflammatory tenosynovitis, extensive volar Brunner incisions are typically used to perform a tenosynovectomy. The diseased tenosynovium is excised, while the anular pulleys are carefully preserved.

Infectious tenosynovitis

In the case of PFT, remove the dressing, splint, and drains, and inspect the wounds approximately 24-48 hours after surgery. Initiate active and passive ROM exercises, as well as soapy soaks or whirlpool treatments. Usually, a removable splint is fabricated and elevation is continued.

For persistent infection, repeat operative débridement may be required. IV antibiotics should continue for an additional 48-72 hours; the length of IV antibiotic treatment is determined by the culture and sensitivity results and by specific patient factors. The switch from IV to oral antibiotics should be based not only on culture results but also on the clinical examination and patient progress. Oral antibiotics should be continued for 5-14 days, depending on the following:

• Intraoperative findings
• Comorbidities
• Organism isolated
• Response to therapy

Generally, the wounds should be left open so they can heal promptly by secondary intention. Delayed primary closure is not needed.

Inflammatory tenosynovitis

During the postoperative course of tenosynovectomy performed for inflammatory tenosynovitis, remove the patient’s bandage, splint, and drain (if used) at 24-48 hours post surgery. At that time, an intrinsic plus resting splint is fabricated. Wounds are fully closed at the time of the index procedure. Sutures can be removed 7-14 days postoperatively, depending on the condition of the rheumatoid skin.

Consultations and referrals may include the following:

• Primary care or hand specialty outpatient referral for follow-up care of de Quervain tenosynovitis and trigger finger
• Emergency medical or hand specialty consultation for suspected gonococcal tenosynovitis for hospital admission and IV antibiotics
• Emergency hand specialty consultation for nongonococcal infectious tenosynovitis for hospital admission, IV antibiotics, and possible surgical drainage

For infectious tenosynovitis, provide follow-up 72 hours after IV antibiotics have been stopped to ensure that the oral regimen is adequate and that no relapse of infection has occurred. Follow-up should continue until the infection has resolved, the wounds are closed, and full motion has returned. Monitor the patient until pain-free motion and strength have been maximized.

For inflammatory tenosynovitis, hand therapy is started at 24-48 hours after the procedure and should consist of gentle active ROM exercises, along with swelling and pain modalities. Near-full active ROM can be achieved by around 3 weeks, after which time cautious strengthening can be added. However, it is not uncommon for progress to be slow, resulting in a rehabilitation course lasting 3-4 months.