AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

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 (GC) infections and other infectious etiologies.

Pathophysiology

Flexor tendons of the hand run in tight fibroosseous tunnels. Visceral and parietal layers of synovium lubricate and nourish the tendons. These layers usually are 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. Overuse leads to inflammation in de Quervain tenosynovitis. Etiology of volar flexor tenosynovitis is unknown.

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.¹

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

History

• de Quervain tenosynovitis
• • Patients have a history of repetitive pinching motion of the thumb and fingers (eg, assembly line work, driving in screws, weeding).
  • Pain in the radial aspect of the wrist becomes worse with activity and better with rest. Onset of pain is typically gradual in nature with no history of acute trauma.
  • Most common in middle-aged women
• Volar flexor tenosynovitis (ie, trigger finger)
• • This type of tenosynovitis most commonly affects the thumb or ring finger.
  • Most common in middle-aged women
  • More common in patients with diabetes
  • Locking of involved finger in flexion is followed by sudden release (hence the name trigger finger); hand pain radiates to fingers. In more severe cases, the finger may require passive manipulation to regain extension.
• Gonococcal tenosynovitis
• • This type of inflammation most commonly affects teenagers and young adults; gonococcal tenosynovitis is more common in women, especially during pregnancy or after menstruation, when dissemination of gonorrhea is more likely to occur.
  • Interval from sexual exposure to onset of symptoms of dissemination can vary from 1 day to several weeks.
  • Vaginal or penile discharges are usually absent; fever, chills, malaise, and polyarthralgias are common.
  • Most common sites affected are the dorsum of the wrist, hand, and ankle.
• Nongonococcal infectious tenosynovitis
• • A puncture wound, dry cracked skin, laceration, bite, or high-pressure injection injury (eg, paint, grease gun) may be present.
  • Frequently no obvious portal of injury is present.
  • Pain and swelling occur along affected tendon; flexor hand tendons are involved most commonly.

Physical

• de Quervain tenosynovitis
• • Pain occurs on palpation along the radial aspect of the wrist.
  • Pain occurs with passive range of motion of the thumb.
  • Pain occurs with ulnar deviation of the wrist with the thumb cupped in a closed fist (ie, Finkelstein test).
• Volar flexor tenosynovitis (ie, trigger finger)
• • Tenderness is present at the proximal end of the tendon sheath, in the distal palm (just proximal to metacarpal head).
  • Palpable tendon thickening and nodularity may be present.
  • Crepitation and catching of the tendon may be appreciated when the finger is flexed.
• Gonococcal tenosynovitis
• • Erythema, tenderness to palpation, and painful range of motion of the involved tendon(s) are present.
  • Fever is common.
  • Dermatitis is also common (occurs in approximately two thirds of disseminated gonococcal) and is characterized by hemorrhagic macules or papules on the distal extremities or trunk.
• Nongonococcal infectious tenosynovitis
• • Tenderness, erythema, and painful range of motion of the involved tendon(s) are present.
  • Cardinal signs of Kanavel include the following: (1) fusiform swelling of the finger (swelling along the whole digit), (2) flexed position of the finger, (3) severe pain with passive extension of the finger, and (4) tenderness and swelling along and limited to the flexor tendon sheath.

Causes

• de Quervain tenosynovitis: Overuse leads to thickening of the extensor retinaculum of the first dorsal compartment and narrowing of the fibroosseous canal.
• Volar flexor tenosynovitis (ie, trigger finger): Overuse is thought to be the most common cause, but multiple etiologies have been identified. The triggering phenomenon is thought to be caused by hypertrophy of the first annular pulley. 
• Gonococcal tenosynovitis - Neisseria gonorrhoeae
• Nongonococcal infectious tenosynovitis
• • Staphylococcus aureus and Streptococcus species are the most common etiologic agents, but infection frequently is mixed (aerobic and anaerobic).
  • Pasteurella multocida is common with cat bites; Eikenella corrodens occurs with human bites. However, human and animal bites may have a mixture of aerobic and anaerobic flora.
  • Predisposing factors include diabetes mellitus, intravenous (IV) drug abuse, debility, and arteriosclerosis obliterans.
  • Mycobacterium species also can cause tenosynovitis, particularly in immunocompromised patients.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Other Problems to be Considered

Osteoarthritis
Subcutaneous abscess

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Lab Studies

• Gonococcal cultures of the urethra or cervix, rectum, and pharynx are appropriate if gonococcal tenosynovitis is suspected. One of these cultures is positive in approximately 80% of patients.
• Complete blood count (CBC) with differential is appropriate if an infectious etiology is suspected.
• Erythrocyte sedimentation rate (ESR) is appropriate if an infectious etiology is suspected.
• Transiently elevated liver function studies have been described with disseminated gonococcal infection.

Imaging Studies

• Radiographs are low yield, unless a retained radiopaque soft tissue foreign body is suspected or if they are needed to rule out a fracture.
• Magnetic resonance imaging (MRI) has proven accurate in assisting the diagnosis of tenosynovitis; however, it is expensive and generally unnecessary since the diagnosis is usually clinically evident.

Procedures

• Diagnostic arthrocentesis is indicated if joint effusion is present with tenosynovitis because most patients with disseminated gonococcal infection have coexistent septic arthritis.
• • Sterile fluid is common with gonococcal arthritis; cultures are negative in 50% of patients.
  • Most gonococcal arthritis is monoarticular; approximately 25% is polyarticular.
  • Joint fluid glucose usually is normal.
  • White blood cell (WBC) counts usually are less than 50,000, and a Gram stain is positive in only 25% of patients.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

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

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

The goals of therapy are to reduce pain and eradicate infection.

Drug Category: 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.

Drug Category: Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Drug Category: 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.

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Further Inpatient Care

• Hospitalization is required for gonococcal and other infectious tenosynovitis.
• Repetitive joint aspirations may be required if septic arthritis is associated with infectious tenosynovitis.

Transfer

• Unavailability of hospital beds, operative capability, or specialty consultation is reason to transfer the patient to another facility.

Complications

• Chronic disability/decreased range of motion
• Chronic pain
• Amputation can be a complication of advanced pyogenic flexor tenosynovitis.

Prognosis

• de Quervain tenosynovitis - Very good with conservative therapy
• Volar flexor tenosynovitis - Good with corticosteroid injection
• Gonococcal tenosynovitis
• • Good with antibiotic therapy
  • Destruction of tendon, cartilage, or bone rare with disseminated gonococcal infection
• Nongonococcal infectious tenosynovitis - Only fair, even with early surgical intervention and antibiotic therapy

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical/Legal Pitfalls

• Failure to consider gonococcal infection in sexually active patients with symptoms and signs of tendinitis and/or tenosynovitis
• Failure to diagnose and emergently refer patients with pyogenic flexor tenosynovitis to appropriate hand specialist for possible surgical drainage

ACKNOWLEDGMENTS

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

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

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

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2. 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].
3. 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].
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5. 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].
6. 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].
7. Brook I. Management of human and animal bite wounds: an overview. Adv Skin Wound Care. May 2005;18(4):197-203. [Medline].
8. Goldenberg DL. Gonococcal arthritis. In: McCarty DJ, ed. Arthritis and Allied Conditions: A Textbook of Rheumatology. 11^th ed. Philadelphia, Pa: Lea and Febiger; 1989.
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10. 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].
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14. 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].
15. Ryzewicz M, Wolf JM. Trigger digits: principles, management, and complications. J Hand Surg [Am]. Jan 2006;31(1):135-46. [Medline].
16. 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].
17. Scopelitis E, Martinez-Osuna P. Gonococcal arthritis. Rheum Dis Clin North Am. May 1993;19(2):363-77. [Medline].
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Article Last Updated: Mar 31, 2008