Tenosynovitis
| Tenosynovitis | |
|---|---|
| Specialty | Physical medicine and rehabilitation  |
Tenosynovitis is the inflammation of the fluid-filled sheath (called the synovium) that surrounds a tendon, typically leading to joint pain, swelling, and stiffness. Tenosynovitis can be either infectious or noninfectious. Common clinical manifestations of noninfectious tenosynovitis include de Quervain tendinopathy and stenosing tenosynovitis (more commonly known as trigger finger)[1]
Pathogenesis
Tenosynovitis most commonly results from the introduction of bacteria into a sheath through a puncture or laceration wound, though bacteria can also be spread from adjacent tissue or via hematogenous spread.[1] The clinical presentation is therefore as acute infection following trauma. The infection can be mono- or polymicrobial and can vary depending on the nature of the trauma. The most common pathogenic agent is staphylococcus aureus introduced from the skin.[2] Other bacteria linked to infectious tenosynovitis include Pasteurella multocida (associated with animal bites), Eikenella spp. (associated with IV drug use), and Mycobacterium marinum (associated with wounds exposed to fresh or salt water).[3] Additionally, sexually active patients are at risk for hematogenous spread due to Neisseria gonorrhea (see infectious arthritis).
Noninfectious tenosynovitis can arise from overuse or secondary to other systemic inflammatory conditions such as [rheumatoid arthritis] or [reactive arthritis].[4] If left untreated, the tendons may undergo stenosis, causing conditions such as de Quervain’s and trigger finger.
Clinical Features
The most common manifestation of infectious tenosynovitis is in the flexor tendons of the fingers, though infections of other tendon sheaths have been reported as well.[5] The four cardinal signs of infectious flexor tenosynovitis are tenderness to touch along the flexor aspect of the finger, symmetric enlargement of the affected finger, the finger being held in slight flexion at rest, and severe pain with passive extension.[6] Fever may also be present but is uncommon.[7]
Diagnosis
Diagnosis of tenosynovitis is typically made clinically after a thorough patient history and physical exam. Aspirated fluid can also be cultured to identify the infectious organism. X-rays are typically unremarkable but can help rule out a broken bone or a foreign body[1]
Treatment
The mainstay of treatment for tenosynovitis includes symptom alleviation, antibiotic therapy, and surgery.[8] Mild tenosynovitis causing small scale swelling can be treated with non-steroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation and as an analgesic. Resting the affected tendons is essential for recovery; a brace is often recommended. Physical or occupational therapy may also be beneficial in reducing symptoms.
Most infectious tenosynovitis cases should be managed with tendon sheath irrigation and drainage, with or without debridement of surrounding necrotic tissue, along with treatment with broad-spectrum antibiotics.[5] In severe cases, amputation may even be necessary to prevent the further spread of infection. Following surgical intervention, antibiotic therapy is continued and adjusted based on the results of the fluid culture.[5]
Prognosis
Treatment for infectious tenosynovitis is more effective the earlier the condition is identified and treated.[8] Factors that worsen patient outcomes include being older than 43, having diabetes mellitus, and a polymicrobial infection.[8]
See also
Notes
- ^ a b c Sexton, MD, Daniel. "Infectious Tenosynovitis". Uptodate.
- ^ Moses MD, Scott. "Suppurative Tenosynovitis". www.fpnotebook.com.
- ^ Tsai, E; Failla, JM (May 1999). "Hand infections in the trauma patient". Hand clinics. 15 (2): 373–86. PMID 10361644.
- ^ Blazar MD, Philip; Aggarwal MD Msc, Rohit. "Trigger finger (stenosing flexor tenosynovitis)". www.uptodate.com.
- ^ a b c Small, LN; Ross, JJ (December 2005). "Suppurative tenosynovitis and septic bursitis". Infectious disease clinics of North America. 19 (4): 991–1005, xi. doi:10.1016/j.idc.2005.08.002. PMID 16297744.
- ^ Pang, HN; Teoh, LC; Yam, AK; Lee, JY; Puhaindran, ME; Tan, AB (August 2007). "Factors affecting the prognosis of pyogenic flexor tenosynovitis". The Journal of bone and joint surgery. American volume. 89 (8): 1742–8. doi:10.2106/JBJS.F.01356. PMID 17671013.
- ^ Nikkhah, D; Rodrigues, J; Osman, K; Dejager, L (2012). "Pyogenic flexor tenosynovitis: one year's experience at a UK hand unit and a review of the current literature". Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the Asia-Pacific Federation of Societies for Surgery of the Hand. 17 (2): 199–203. doi:10.1142/S0218810412500190. PMID 22745083.
- ^ a b c Giladi, AM; Malay, S; Chung, KC (September 2015). "A systematic review of the management of acute pyogenic flexor tenosynovitis". The Journal of hand surgery, European volume. 40 (7): 720–8. doi:10.1177/1753193415570248. PMID 25670687.