Tenosynovitis is the

inflammation Inflammation (from la, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants, and is a protective response involving immune cells, blood vessels, and molec ...

of the fluid-filled sheath (called the

synovium The synovial membrane (also known as the synovial stratum, synovium or stratum synoviale) is a specialized connective tissue that lines the inner surface of capsules of synovial joints and tendon sheath. It makes direct contact with the fibrous ...

) that surrounds a

tendon A tendon or sinew is a tough, high-tensile-strength band of dense fibrous connective tissue that connects muscle to bone. It is able to transmit the mechanical forces of muscle contraction to the skeletal system without sacrificing its ability ...

, 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 Trigger finger, also known as stenosing tenosynovitis, is a disorder characterized by catching or locking of the involved finger in full or near full flexion, typically with force. There may be tenderness in the palm of the hand near the last ...

)

Signs and symptoms

Infectious tenosynovitis occurs between 2.5% and 9.4% of all hand infections. Kanavel's cardinal signs is used to diagnose infectious tenosynovitis. They are: tenderness to touch along the flexor aspect of the finger, fusiform enlargement of the affected finger, the finger being held in slight flexion at rest, and severe pain with passive extension. Fever may also be present but is uncommon.

Pathogenesis

Infectious tenosynovitis is the infection of closed

synovial sheath A synovial sheath is one of the two membranes of a tendon sheath which covers a tendon. The other membrane is the outer fibrous tendon sheath. The tendon invaginates the synovial sheath from one side so that the tendon is suspended from the membra ...

s in the flexor tendons of the fingers. It is usually caused by trauma, but bacteria can spread from other sites of the body. Although tenosynovitis usually affects the flexor tendon of the fingers, the disease can also affect the extensor tendons occasionally. 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 ''Staphylococcus aureus'' is a Gram-positive spherically shaped bacterium, a member of the Bacillota, and is a usual member of the microbiota of the body, frequently found in the upper respiratory tract and on the skin. It is often posit ...

'' introduced from the skin. Other bacteria linked to infectious tenosynovitis include ''

Pasteurella multocida ''Pasteurella multocida'' is a Gram-negative, nonmotile, penicillin-sensitive coccobacillus of the family Pasteurellaceae. Strains of the species are currently classified into five serogroups (A, B, D, E, F) based on capsular composition and ...

'' (associated with animal bites), ''

Eikenella ''Eikenella corrodens'' is a Gram-negative facultative anaerobic bacillus that can cause severe invasive disease in humans. It was first identified by M. Eiken in 1958, who called it ''Bacteroides corrodens''. ''E. corrodens'' is a rare pericar ...

'' spp. (associated with IV drug use), and '' Mycobacterium marinum'' (associated with wounds exposed to fresh or salt water). Additionally, sexually active patients are at risk for hematogenous spread due to ''

Neisseria gonorrhoeae ''Neisseria gonorrhoeae'', also known as ''gonococcus'' (singular), or ''gonococci'' (plural), is a species of Gram-negative diplococci bacteria isolated by Albert Neisser in 1879. It causes the sexually transmitted genitourinary infection gon ...

'' (see

infectious arthritis Acute septic arthritis, infectious arthritis, suppurative arthritis, osteomyelitis, or joint infection is the invasion of a joint by an infectious agent resulting in joint inflammation. Generally speaking, symptoms typically include redness, he ...

). Common noninfectious tenosynovitis are: stenosing tenosynovitis, intersection syndrome,

extensor pollicis longus In human anatomy, the extensor pollicis longus muscle (EPL) is a skeletal muscle located dorsally on the forearm. It is much larger than the extensor pollicis brevis, the origin of which it partly covers and acts to stretch the thumb together ...

(EPL) tenosynovitis, de Quervain's and fourth compartment tenosynovitis.

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

Treatment

The mainstay of treatment for infectious tenosynovitis includes symptom relief, antibiotic therapy, and surgery. Early recognition of the disease with early initiation of antibiotics are important for better range of movement of the affected finger. Minimally invasive procedures into the flexor tendon sheath such as catheter irrigation give better outcomes (74% chance of good outcome) when compared to open surgery (26% chance of good outcome). However, wound irrigation with antibiotics has no clear benefits. 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. 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.

Prognosis

The earlier the condition is identified, the better the chance of getting full range of motion of the finger. However, finger stiffness,

Boutonniere deformity Boutonniere deformity is a deformed position of the fingers or toes, in which the joint nearest the knuckle (the proximal interphalangeal joint, or PIP) is permanently bent toward the palm while the farthest joint (the distal interphalangeal joi ...

, deep space infection, tendon necrosis, adhesions, persistent infection, and need for amputation of the finger can occur. Tendon adhesion and finger stiffness are caused by the violation of the flexor tendon sheath.

Notes

External links

http://orthoinfo.aaos.org

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