Tenosynovitis

Tenosynovitis

1. Tenosynovitis

2. Definition Etiology Prognosis Pathophysiology History Physical examination Work up Treatment Postoperative care Rare disorders

3. Tenosynovitis definition A group of entities with a common pathology involving the extrinsic tendons of the hand and wrist and their corresponding retinacular sheaths. Burman M. Stenosing tendovaginitis of the dorsal and volar compartments of the wrist. AMA Arch Surg. 1952 Nov;65(5):752-62

4. Start as tendon irritation and pain Progress into catching and locking when tendon glides

5. Synonyms: Tendinitis Tendovaginitis Misleading names Tendinosis , most appropriate descriptor

6. Etiology

7. Noninfectious causes Diabetes mellitus Rheumatoid arthritis Crystalline deposition Overuse syndromes Amyloidosis Ochronosis Psoriatic arthritis Systemic lupus erythematosus Sarcoidosis

8. Overuse injury De Quervain tenosynovitis Volar flexor tenosynovitis ( ie , trigger finger)

9. Nongonococcal infectious tenosynovitis Staphylococcus aureus  and  Streptococcus  species - most common etiologic agents Pasteurella multocida Eikenella corrodens  - Higher incidence with human bite wounds Anaerobes -  Bacteroides  and  Fusobacterium  species most common Haemophilus  species Capnocytophaga canimorsus

10. Miscellaneous gram-negative organisms Mycobacterium tuberculosis Other  Mycobacterium  species Clostridium difficile Pseudomonas aeruginosa Listeria monocytogenes Vibrio vulnificus

11. Gonococcal tenosynovitis Neisseria gonorrhoeae   (originates as a mucosal infection of the genital tract, rectum, or pharynx).

12. Pyogenic flexor tenosynovitis Infectious agent multiplying in the closed space of the flexor tendon sheath and culture-rich synovial fluid medium. Natural immune response mechanisms cause swelling and migration of inflammatory cells and mediators

13. Epidemiology One third of all cases of hand and finger FT are associated with diabetes mellitus 64-95 % of patients with RA develop hand or wrist FT

14. Prognosis Good prognosis Present early N o comorbidities . Long-term complications and impairment Fulminant infection Chronic infection Impaired immune status

15. Complications Loss of range of motion (ROM) secondary to adhesions ( most common) Soft-tissue necrosis Flexor tendon rupture

16. Risk factors were associated with poorer outcomes   : Age over 45 years Presence of diabetes mellitus, renal failure, or peripheral vascular disease Ischemic changes at the time of presentation Subcutaneous purulence Polymicrobial infection at the time of surgery

17. FT that is diagnosed by magnetic resonance imaging (MRI) is a strong predictor of early RA Among patients with stenosing FT, those with diabetes have a higher prevalence of multiple joint involvement than do those without diabetes

18. Pathophysiology

19. Inflammatory flexor tenosynovitis Inflammatory stage Starts immediately 48 hours to 2 weeks Release of chemotactic and vasoactive substances; the resulting inflammatory cells create pain, swelling, erythema , and warmth Proliferative stage Lasts up to 2 weeks Production of collagen and ground substances; the tendon is extremely vulnerable to injury Maturation stage Lasts up to 12 weeks Healing phases are completed. if the inflammatory response is reinitiated at this time, fibrosis can result

20. Infectious flexor tenosynovitis Closed-space infection.  Tendon sheath inner visceral layer outer parietal layer. Between the two layers is the synovial space, which is filled with synovial fluid

21. Accumulation of pus in flexor tendon sheath infections Pressure increases (in excess of 30 mg Hg) Inhibiting the inflammatory response. Inhibits blood flow Tendon ischemia increases the likelihood of tendon necrosis and rupture

22. History

23. Gonococcal Teenagers and young adults More common in women Dorsum of the wrist, hand, and ankle

24. Nongonococcal infectious tenosynovitis Dry, cracked skin or a puncture wound, laceration, bite, or high-pressure injection injury Flexor hand tendons

25. De Quervain tenosynovitis Pain in the radial aspect of the wrist Worse with activity and better with rest History of repetitive pinching motion of the thumb and fingers Middle-aged women No history of acute trauma

26. Volar flexor tenosynovitis Thumb or ring finger Middle-aged women Diabetics Locking of the involved finger in flexion is followed by sudden release (hence the name trigger finger ) Hand pain radiates to fingers

27. Physical Examination

28. Infectious tenosynovitis

29. Kanavel signs may be absent in: Recently administered antibiotics Early manifestations of the condition Immunocompromised state Chronic infections

30. Volar flexor tenosynovitis Tenderness 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

31. De Quervain tenosynovitis 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

32. Swelling is most common initial finding. As the tissue expands and impingement occurs, pain and restricted motion. Delayed presentations: fulminant FT with all Kanavel signs or tendon rupture.

33. Differential Diagnoses Herpetic whitlow Pyarthrosis Gout Pseudogout Dactylitis Phalanx fracture Arthritis Osteoarthritis Subcutaneous abscess

34. Sesamoiditis and angiolipoma Hand infections Hand injury, high pressure Hand injury, soft tissue Reactive arthritis Rheumatic fever

35. Workup

36. Laboratory Studies CBC ESR Rheumatoid factor Gonococcal cultures of the urethra or cervix, rectum, and pharynx

37. Imaging Studies Anteroposterior and lateral radiographs to rule out bony involvement or a foreign body Magnetic resonance imaging ( MRI)-accurate

38. Aspiration and Evaluation of Joint Fluid Sterile fluid is common with gonococcal arthritis; cultures are negative in 50% of patients Joint fluid glucose is usually normal. White blood cell (WBC) counts are usually below 50,000/ μL A Gram stain is positive in only 25% of patients Cultures should include aerobic, anaerobic, fungal, acid-fast bacilli (AFB), and atypical AFB Nonbirefringent crystals (gout) or birefringent crystals (calcium pyrophosphate disease [CPPD], or pseudogout )

39. Histologic Findings Synovial biopsy for inflammatory arthropathy . Granulomatous changes observed in  Mycobacterium  infections and in cases of chronic processes

40. Treatment

41. Infectious flexor tenosynovitis Nonoperatively :- Nonsuppurative Surgical intervention:- Chronic conditions Immunocompromised Diabetes 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 Mycobacterium  species infection, extensive tenosynovectomy

42. Nonoperative treatment: IV antibiotics Elevation - Initially, until infection is under control Splinting - In “safe position” Rehabilitation - Digital range-of-motion (ROM) exercises and edema control, initiated once FT is under control

43. Michon Classification Scheme

44. Proximal incision: A1 pulley Distal incision: A5 pulley 16-gauge polyethylene catheter or a 3.5-5 French feeding tube Irrigated with a minimum of 500 mL of normal saline

45. Inflammatory flexor tenosynovitis Nonoperative management Refractory to at least 3-6 months of good medical management or in patients with tendon ruptures, Tenosynovectomy

46. Icing and elevation of the affected area NSAID Short course of oral steroids Flexor tendon sheath or carpal tunnel corticosteroid injections Splinting - limited in area to a pain-free ROM Rehabilitation - Slow rehabilitation prevents reinitiation of the inflammatory phase

47. De Quervain tenosynovitis Rest , NSAIDs, and a thumb spica wrist splint for patients with minimal symptoms Peritendinous lidocaine -corticosteroid injection: initial treatment of choice Corticosteroid treatment: cure rate of greater than 80% & safe

48. Volar flexor tenosynovitis Peritendinous lidocaine -corticosteroid injection is the treatment of choice 12-month follow-up phase Surgical release for trigger finger has success rates higher than 90%

49. Rheumatoid arthritis Ice , NSAIDs, rest, splinting, hydroxychloroquine , gold, penicillamine , and methotrexate . Persistent cases: oral steroid treatment. Acute flares: corticosteroid injections 

50. Postoperative Care

51. Infectious flexor tenosynovitis 48 hours after surgery, remove the dressing, splint, and drains, and inspect the wounds Initiate active and passive ROM exercises Removable splint is fabricated and elevation is continued Persistent infection, repeat operative débridement

52. Oral antibiotics be continued for 5-14 days, depending on: Intraoperative findings Comorbidities Organism isolated Response to therapy Wounds should be left open so they can heal promptly by secondary intention. Delayed primary closure is not needed.

53. Inflammatory flexor tenosynovitis Remove the patient’s bandage, splint, and drain (if used) at 24-48 hours post surgery. 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

54. At 24-48 hours: Hand therapy started consist of gentle, active ROM exercises, along with swelling and pain modalities. Around 3 weeks: Near-full active ROM Strengthening exercises Rehabilitation course lasting 3-4 months

55. Rare disorders Intersection Syndrome Extensor Pollicis Longus Tenosynovitis Fourth Compartment Tenosynovitis Extensor Carpi Ulnaris Tenosynovitis

56. Intersection Syndrome Occurs when the APL and EPB bellies rub on the ECRB & ECRL tendons Secondary to repetitive flexion and extension movements during occupation or sporting activities

57. Differentials: De Quervain disorder Wartenberg syndrome (neuritis of the dorsal sensory branch of the radial nerve as it exits from under the brachioradialis tendon in the forearm) Tendinitis of the second or third compartment Muscle strain G anglion cyst

58. Treatment: Cessation of the aggravating activity NSAIDs Splinting of the wrist in slight extension, including the thumb to the interphalangeal join Local corticosteroid injections Surgical decompression of the second dorsal compartment

59. Extensor Pollicis Longus Tenosynovitis EPL tendon becomes thickened and inflamed. Pain and triggering at the level of the Lister tubercle of the third extensor compartment Etiology : Drummer palsy Inflammatory conditions such as rheumatoid arthritis Inflammation resulting from minimally displaced distal radial fractures

60. Treatment: Corticosteroid injection Surgical release of the tendon sheath

61. Fourth Compartment Tenosynovitis Proliferative tenosynovitis C ommon in patients with rheumatoid arthritis Painful dorsal wrist mass that moved with the extensor tendons and had substantially more pain with extension of the wrist with the fingers extended than with the fingers flexed Tenosynovectomy to prevent rupture of the tendon

62. Extensor Carpi Ulnaris Tenosynovitis Racquet sport players Ulnar -sided wrist pain Pain with forced isometric supination Differentials: Triangular fibrocartilage complex ( TFCC) injury D istal radioulnar joint injury

63. Corticosteroid injection Decompression of the extensor carpi ulnaris Synovial thickening: adequate decompression without releasing the entire retinaculum over the ECU tendon ECU tendon is irritated by chronic subluxation with wrist pronation-supination : ECU is stabilized with use of a slip of the extensor retinaculum