Tenosynovitis

Basics

Description

  • Inflammation of the tendon and tendon sheath
  • Most common in the hand, wrist, and foot
  • Caused by noninfectious (autoimmune, overuse, idiopathic) or infectious processes
  • Tendon sheaths consist of synovial sheaths or bursa that cover tendons, as well as osseofibrous tunnels that tendons pass through:
    • Visceral and parietal layers of the synovium lubricate and nourish the tendons
    • Infection can be introduced into tendon sheath
  • Pathophysiology:
    • Inflammation and thickening as a result of purulence, autoimmune complexes, crystalline deposits, overuse, or other etiology
    • Natural gliding of tendon is disrupted
    • Infectious tenosynovitis has 3 stages:
      1. Distension of the sheath by exudate
      2. Purulent material invades the sheath
      3. Necrosis and cell death occurs within the sheath
  • Causes of infectious tenosynovitis:
    • Skin wound – penetrating injury especially at flexion creases of the finger is most common mechanism that causes flexor tenosynovitis of the hand
    • Hematogenous spread
    • Nongonococcal infectious tenosynovitis:
      • Staphylococcus aureus and Streptococci are most common in penetrating injuries
      • Pasteurella multocida is common with cat bites
      • Eikenella corrodens is common in human bites
      • Pseudomonas is seen in patients with diabetes or marine-associated injuries
      • Mycobacterium species may occur in immunocompromised patients
      • Fungal tenosynovitis may occur from puncture wounds due to thorns or woody plants
  • GC tenosynovitis:
    • Caused by Neisseria Gonorrhea
    • Most commonly affects teenagers, young adults
    • Seen in the ankle, hand, or wrist
    • More commonly seen in women
    • Vaginal or penile discharge usually absent
    • Fever, chills, polyarthralgia are common
    • Erythema, tenderness to palpation, and painful range of motion of the involved tendon
    • Dermatitis may be present
    • Hemorrhagic macules or papules on the distal extremities or trunk
  • High-pressure “injection” injury to fingers – may appear minor on the surface but are associated with high incidence of FTS
  • Examples:
    • Air tools
    • Paint sprayers
    • Hydraulic equipment
  • Causes of noninfectious tenosynovitis:
    • De Quervain tenosynovitis:
      • Caused by overuse
      • Repetitive pinching motion of thumb and fingers
      • Inflammatory in nature
      • Two thumb tendons can be affected: The abductor pollicis longus (APL) and extensor pollicis brevis (EPB)
      • Along the path to the thumb, the APL and EPB traverse side-by-side through a thick fibrous sheath that forms a tunnel at the radial styloid process
      • Assembly-line workers
      • Carpenters
      • Landscaping or weeding
    • Rheumatoid tenosynovitis
    • Psoriatic tenosynovitis
  • Traumatic tenosynovitis is seen after a direct blow to the lower portion of the forearm

Epidemiology

  • Incidence approximately 2% in the general population
  • Higher among diabetics
  • Higher among rheumatoid and psoriatic arthritis

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