Tenosynovitis

Tenosynovitis is a topic covered in the 5-Minute Emergency Consult.

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Basics

Description

  • Definition:
    • Inflammation and pain of the tendon and tendon sheath
    • Caused by acute or chronic inflammation, overuse, or infection
    • Can lead to pain, decreased ROM, necrosis, and tendon rupture
  • Anatomy:
    • Synovial sheaths cover tendons as they pass through osseofibrous tunnels
    • Visceral and parietal layers of the synovium lubricate and nourish the tendons
  • Pathophysiology:
    • Inflammation: Proliferation of fibrous tissue causing painful friction, impingement/constriction of the tendon. High association with DM and RA
    • Overuse: Repetitive microtrauma resulting in inflammation and fibrosis
    • Infection: Most common in acute setting:
      • Introduced into tendon sheath via:
        • Skin wound/puncture is most common
        • Hematogenous spread
  • Flexor tenosynovitis (FTS) of hand: Closed space infection of the flexor tendons. An orthopedic emergency
    • Most common mechanism is penetrating injury at flexion creases of the finger
    • Causes include:
      • Penetrating trauma
      • Bites
      • High-pressure injection (Paint sprayer, grease gun)
      • Air tools
      • Hydraulic equipment: May appear minor on the surface but are associated with high incidence of FTS
      • Hematogenous or direct spread from deep space or joint infection

Etiology

  • de Quervain tenosynovitis:
    • Caused by overuse
    • Inflammatory in nature
    • Two thumb tendons: The abductor pollicis longus (APL) and extensor pollicis brevis (EPB)
    • Near the thumb base, the APL and EPB traverse together through a thick fibrous sheath forming a tunnel at the radial styloid process
    • Overuse causes thickening of extensor retinaculum and subsequent canal narrowing
  • Nongonococcal infectious tenosynovitis:
    • Staphylococcus aureus and Streptococci are most common in penetrating injuries, but often polymicrobial
    • Pasteurella multocida associated with cat bites
    • Eikenella corrodens associated with human bites
    • Pseudomonas is seen in patients with diabetes or marine-associated injuries
    • Mycobacterium species may occur in immunocompromised patients. Suspect in chronic, indolent infections
  • Gonococcal tenosynovitis:
    • Disseminated Neisseria gonorrhoeae
  • Fungal tenosynovitis may occur from puncture wounds due to thorns or woody plants

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Basics

Description

  • Definition:
    • Inflammation and pain of the tendon and tendon sheath
    • Caused by acute or chronic inflammation, overuse, or infection
    • Can lead to pain, decreased ROM, necrosis, and tendon rupture
  • Anatomy:
    • Synovial sheaths cover tendons as they pass through osseofibrous tunnels
    • Visceral and parietal layers of the synovium lubricate and nourish the tendons
  • Pathophysiology:
    • Inflammation: Proliferation of fibrous tissue causing painful friction, impingement/constriction of the tendon. High association with DM and RA
    • Overuse: Repetitive microtrauma resulting in inflammation and fibrosis
    • Infection: Most common in acute setting:
      • Introduced into tendon sheath via:
        • Skin wound/puncture is most common
        • Hematogenous spread
  • Flexor tenosynovitis (FTS) of hand: Closed space infection of the flexor tendons. An orthopedic emergency
    • Most common mechanism is penetrating injury at flexion creases of the finger
    • Causes include:
      • Penetrating trauma
      • Bites
      • High-pressure injection (Paint sprayer, grease gun)
      • Air tools
      • Hydraulic equipment: May appear minor on the surface but are associated with high incidence of FTS
      • Hematogenous or direct spread from deep space or joint infection

Etiology

  • de Quervain tenosynovitis:
    • Caused by overuse
    • Inflammatory in nature
    • Two thumb tendons: The abductor pollicis longus (APL) and extensor pollicis brevis (EPB)
    • Near the thumb base, the APL and EPB traverse together through a thick fibrous sheath forming a tunnel at the radial styloid process
    • Overuse causes thickening of extensor retinaculum and subsequent canal narrowing
  • Nongonococcal infectious tenosynovitis:
    • Staphylococcus aureus and Streptococci are most common in penetrating injuries, but often polymicrobial
    • Pasteurella multocida associated with cat bites
    • Eikenella corrodens associated with human bites
    • Pseudomonas is seen in patients with diabetes or marine-associated injuries
    • Mycobacterium species may occur in immunocompromised patients. Suspect in chronic, indolent infections
  • Gonococcal tenosynovitis:
    • Disseminated Neisseria gonorrhoeae
  • Fungal tenosynovitis may occur from puncture wounds due to thorns or woody plants

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