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![Aspiration and Evaluation of Joint Fluid
• Sterile fluid is common with gonococcal arthritis;
cultures are negative in 50% of patients
• Joint fluid glucose is usually normal.
• White blood cell (WBC) counts are usually below
50,000/μL
• A Gram stain is positive in only 25% of patients
• Cultures should include aerobic, anaerobic,
fungal, acid-fast bacilli (AFB), and atypical AFB
• Nonbirefringent crystals (gout) or birefringent
crystals (calcium pyrophosphate disease [CPPD],
or pseudogout)](https://image.slidesharecdn.com/tenosynovitis-210610180127/85/Tenosynovitis-42-320.jpg)
Uploaded byDr Sourabh Shankar Chakraborty
Tenosynovitis
This document discusses tenosynovitis, including its definition, etiology, prognosis, pathophysiology, history, physical examination findings, workup, treatment, and postoperative care. Tenosynovitis is inflammation of the tendon sheath that can be caused by overuse, infection, or inflammatory conditions like rheumatoid arthritis. Physical exam may reveal tenderness, swelling, or limited range of motion. Treatment depends on the cause but may include rest, splinting, anti-inflammatories, corticosteroid injections, or surgery. Prognosis is generally good if treated early without comorbidities, while complications can include adhesion formation or tendon rupture if left untreated.
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Tenosynovitis
- 1.
- 2. • Definition • Etiology •Prognosis • Pathophysiology • History • Physical examination • Work up • Treatment • Postoperative care • Rare disorders
- 3. Tenosynovitis definition • Agroup of entities with a common pathology involving the extrinsic tendons of the hand and wrist and their corresponding retinacular sheaths. • Burman M. Stenosing tendovaginitis of the dorsal and volar compartments of the wrist. AMA Arch Surg. 1952 Nov;65(5):752-62
- 4. • Start astendon irritation and pain • Progress into catching and locking when tendon glides
- 6. • Synonyms: – Tendinitis –Tendovaginitis • Misleading names • Tendinosis, most appropriate descriptor
- 7.
- 8. Noninfectious causes • Diabetesmellitus • Rheumatoid arthritis • Crystalline deposition • Overuse syndromes • Amyloidosis • Ochronosis • Psoriatic arthritis • Systemic lupus erythematosus • Sarcoidosis
- 9. Overuse injury • DeQuervain tenosynovitis • Volar flexor tenosynovitis (ie, trigger finger)
- 10. Nongonococcal infectious tenosynovitis • Staphylococcusaureus and Streptococcus species - most common etiologic agents • Pasteurella multocida • Eikenella corrodens - Higher incidence with human bite wounds • Anaerobes - Bacteroides and Fusobacterium species most common • Haemophilus species • Capnocytophaga canimorsus
- 11. • Miscellaneous gram-negativeorganisms • Mycobacterium tuberculosis • Other Mycobacterium species • Clostridium difficile • Pseudomonas aeruginosa • Listeria monocytogenes • Vibrio vulnificus
- 12. Gonococcal tenosynovitis • Neisseriagonorrhoeae (originates as a mucosal infection of the genital tract, rectum, or pharynx).
- 13. Pyogenic flexor tenosynovitis •Infectious agent multiplying in the closed space of the flexor tendon sheath and culture- rich synovial fluid medium. • Natural immune response mechanisms cause swelling and migration of inflammatory cells and mediators
- 14. Epidemiology • One thirdof all cases of hand and finger FT are associated with diabetes mellitus • 64-95% of patients with RA develop hand or wrist FT
- 15. Prognosis • Good prognosis –Present early – No comorbidities. • Long-term complications and impairment – Fulminant infection – Chronic infection – Impaired immune status
- 16. Complications • Loss ofrange of motion (ROM) secondary to adhesions (most common) • Soft-tissue necrosis • Flexor tendon rupture
- 17. Risk factors wereassociated with poorer outcomes: 1. Age over 45 years 2. Presence of diabetes mellitus, renal failure, or peripheral vascular disease 3. Ischemic changes at the time of presentation 4. Subcutaneous purulence 5. Polymicrobial infection at the time of surgery
- 18. • FT thatis diagnosed by magnetic resonance imaging (MRI) is a strong predictor of early RA • Among patients with stenosing FT, those with diabetes have a higher prevalence of multiple joint involvement than do those without diabetes
- 19.
- 20. Inflammatory flexor tenosynovitis Inflammatory stage Starts immediately 48hours to 2 weeks Release of chemotactic and vasoactive substances; the resulting inflammatory cells create pain, swelling, erythema, and warmth Proliferative stage Lasts up to 2 weeks Production of collagen and ground substances; the tendon is extremely vulnerable to injury Maturation stage Lasts up to 12 weeks Healing phases are completed. if the inflammatory response is reinitiated at this time, fibrosis can result
- 21. Infectious flexor tenosynovitis •Closed-space infection. • Tendon sheath – inner visceral layer – outer parietal layer. • Between the two layers is the synovial space, which is filled with synovial fluid
- 22. Accumulation of pus inflexor tendon sheath infections Pressure increases (in excess of 30 mg Hg) Inhibiting the inflammatory response. Inhibits blood flow Tendon ischemia increases the likelihood of tendon necrosis and rupture
- 23.
- 24. Gonococcal • Teenagers andyoung adults • More common in women • Dorsum of the wrist, hand, and ankle
- 25. Nongonococcal infectious tenosynovitis • Dry,cracked skin or a puncture wound, laceration, bite, or high-pressure injection injury • Flexor hand tendons
- 26. De Quervain tenosynovitis •Pain in the radial aspect of the wrist • Worse with activity and better with rest • History of repetitive pinching motion of the thumb and fingers • Middle-aged women • No history of acute trauma
- 29. Volar flexor tenosynovitis •Thumb or ring finger • Middle-aged women • Diabetics • Locking of the involved finger in flexion is followed by sudden release (hence the name trigger finger) • Hand pain radiates to fingers
- 31.
- 32.
- 33. Kanavel signs maybe absent in: 1. Recently administered antibiotics 2. Early manifestations of the condition 3. Immunocompromised state 4. Chronic infections
- 34. Volar flexor tenosynovitis •Tenderness at the proximal end of the tendon sheath, in the distal palm (just proximal to the metacarpal head) • Palpable tendon thickening and nodularity may be present • Crepitation and catching of the tendon may be appreciated when the finger is flexed
- 35. De Quervain tenosynovitis •Pain occurs on palpation along the radial aspect of the wrist • Pain occurs with passive ROM of the thumb • Pain occurs with ulnar deviation of the wrist with the thumb cupped in a closed fist
- 36. • Swelling ismost common initial finding. • As the tissue expands and impingement occurs, pain and restricted motion. • Delayed presentations: fulminant FT with all Kanavel signs or tendon rupture.
- 37. Differential Diagnoses • Herpeticwhitlow • Pyarthrosis • Gout • Pseudogout • Dactylitis • Phalanx fracture • Arthritis • Osteoarthritis • Subcutaneous abscess
- 38. • Sesamoiditis andangiolipoma • Hand infections • Hand injury, high pressure • Hand injury, soft tissue • Reactive arthritis • Rheumatic fever
- 39.
- 40. Laboratory Studies • CBC •ESR • Rheumatoid factor • Gonococcal cultures of the urethra or cervix, rectum, and pharynx
- 41. Imaging Studies • Anteroposteriorand lateral radiographs to rule out bony involvement or a foreign body • Magnetic resonance imaging (MRI)-accurate
- 42. Aspiration and Evaluationof Joint Fluid • Sterile fluid is common with gonococcal arthritis; cultures are negative in 50% of patients • Joint fluid glucose is usually normal. • White blood cell (WBC) counts are usually below 50,000/μL • A Gram stain is positive in only 25% of patients • Cultures should include aerobic, anaerobic, fungal, acid-fast bacilli (AFB), and atypical AFB • Nonbirefringent crystals (gout) or birefringent crystals (calcium pyrophosphate disease [CPPD], or pseudogout)
- 43. Histologic Findings • Synovialbiopsy for inflammatory arthropathy. • Granulomatous changes observed in Mycobacterium infections and in cases of chronic processes
- 44.
- 45. Infectious flexor tenosynovitis •Nonoperatively:- Nonsuppurative • Surgical intervention:- – Chronic conditions – Immunocompromised – Diabetes • If medical treatment alone is attempted, then inpatient observation for at least 48 hours is indicated. • Surgical drainage is necessary if no obvious improvement has occurred within 12-24 hours • Mycobacterium species infection, extensive tenosynovectomy
- 46. Nonoperative treatment: • IVantibiotics • Elevation - Initially, until infection is under control • Splinting - In “safe position” • Rehabilitation - Digital range-of-motion (ROM) exercises and edema control, initiated once FT is under control
- 47.
- 48. • Proximal incision:A1 pulley • Distal incision: A5 pulley • 16-gauge polyethylene catheter or a 3.5-5 French feeding tube • Irrigated with a minimum of 500 mL of normal saline
- 49. Inflammatory flexor tenosynovitis •Nonoperative management • Refractory to at least 3-6 months of good medical management or in patients with tendon ruptures, Tenosynovectomy
- 50. • Icing andelevation of the affected area • NSAID • Short course of oral steroids • Flexor tendon sheath or carpal tunnel corticosteroid injections • Splinting - limited in area to a pain-free ROM • Rehabilitation - Slow rehabilitation prevents reinitiation of the inflammatory phase
- 51. De Quervain tenosynovitis •Rest, NSAIDs, and a thumb spica wrist splint for patients with minimal symptoms • Peritendinous lidocaine- corticosteroid injection: initial treatment of choice • Corticosteroid treatment: cure rate of greater than 80% & safe
- 52. Volar flexor tenosynovitis •Peritendinous lidocaine- corticosteroid injection is the treatment of choice • 12-month follow-up phase • Surgical release for trigger finger has success rates higher than 90%
- 53. Rheumatoid arthritis • Ice,NSAIDs, rest, splinting, hydroxychloroquine, gold, penicillamine, and methotrexate. • Persistent cases: oral steroid treatment. • Acute flares: corticosteroid injections
- 54.
- 55. Infectious flexor tenosynovitis •48 hours after surgery, remove the dressing, splint, and drains, and inspect the wounds • Initiate active and passive ROM exercises • Removable splint is fabricated and elevation is continued • Persistent infection, repeat operative débridement
- 57. • Oral antibioticsbe continued for 5-14 days, depending on: – Intraoperative findings – Comorbidities – Organism isolated – Response to therapy • Wounds should be left open so they can heal promptly by secondary intention. Delayed primary closure is not needed.
- 58. Inflammatory flexor tenosynovitis •Remove the patient’s bandage, splint, and drain (if used) at 24-48 hours post surgery. • Intrinsic plus resting splint is fabricated. • Wounds are fully closed at the time of the index procedure. • Sutures can be removed 7-14 days postoperatively
- 59. • At 24-48hours: – Hand therapy started consist of gentle, active ROM exercises, along with swelling and pain modalities. • Around 3 weeks: – Near-full active ROM – Strengthening exercises • Rehabilitation course lasting 3-4 months
- 61. Rare disorders • IntersectionSyndrome • Extensor Pollicis Longus Tenosynovitis • Fourth Compartment Tenosynovitis • Extensor Carpi Ulnaris Tenosynovitis
- 62. Intersection Syndrome • Occurswhen the APL and EPB bellies rub on the ECRB & ECRL tendons • Secondary to repetitive flexion and extension movements during occupation or sporting activities
- 63. Differentials: 1. De Quervaindisorder 2. Wartenberg syndrome (neuritis of the dorsal sensory branch of the radial nerve as it exits from under the brachioradialis tendon in the forearm) 3. Tendinitis of the second or third compartment 4. Muscle strain 5. Ganglion cyst
- 64. Treatment: • Cessation ofthe aggravating activity • NSAIDs • Splinting of the wrist in slight extension, including the thumb to the interphalangeal join • Local corticosteroid injections • Surgical decompression of the second dorsal compartment
- 65. Extensor Pollicis LongusTenosynovitis • EPL tendon becomes thickened and inflamed. • Pain and triggering at the level of the Lister tubercle of the third extensor compartment • Etiology: – Drummer palsy – Inflammatory conditions such as rheumatoid arthritis – Inflammation resulting from minimally displaced distal radial fractures
- 66. Treatment: • Corticosteroid injection •Surgical release of the tendon sheath
- 67. Fourth Compartment Tenosynovitis •Proliferative tenosynovitis • Common in patients with rheumatoid arthritis • Painful dorsal wrist mass that moved with the extensor tendons and had substantially more pain with extension of the wrist with the fingers extended than with the fingers flexed • Tenosynovectomy to prevent rupture of the tendon
- 68. Extensor Carpi UlnarisTenosynovitis • Racquet sport players • Ulnar-sided wrist pain • Pain with forced isometric supination • Differentials: – Triangular fibrocartilage complex (TFCC) injury – Distal radioulnar joint injury
- 69. • Corticosteroid injection •Decompression of the extensor carpi ulnaris – Synovial thickening: adequate decompression without releasing the entire retinaculum over the ECU tendon – ECU tendon is irritated by chronic subluxation with wrist pronation-supination: ECU is stabilized with use of a slip of the extensor retinaculum