Tenosynovitis, an inflammation of the tendon and surrounding synovial sheath, is characterized by pain and tenderness. Pyogenic flexor tenosynovitis is a serious tendon sheath infection resulting from puncture wounds, local extension, or hematogenous spread. It is characterized by the four cardinal Kanavel signs (see Fig. 12.28). Tenosynovitis may be complicated by fibrosis and adhesions, leading to stiffness, loss of function, and tendon necrosis. Inflammatory flexor tenosynovitis is typically due to rheumatoid arthritis, overuse, diabetes mellitus, or connective tissue disorders. The time course is typically more indolent than pyogenic flexor tenosynovitis, although the sequelae can be similar. Intersection syndrome is tenosynovitis of the radial wrist extensors. It causes pain, swelling, and crepitus of these muscle bellies in the distal third of the dorsoradial forearm.
Flexor Tenosynovitis. Pyogenic flexor tenosynovitis of the fourth finger with fusiform swelling, tenderness along the flexor tendon sheath, and pain on flexion. (Photo contributor: Lawrence B. Stack, MD.)
Tenosynovitis. Pyogenic tenosynovitis of the middle finger with fusiform swelling, tenderness along the tendon sheath, and pain on movement. (Photo contributor: Edmond A. Hooker, MD, DrPH.)
Management and Disposition
It is difficult to distinguish infectious and noninfectious causes early (24-48 hours). Management of noninfectious tenosynovitis includes immobilization and NSAIDs. Broad-spectrum parenteral antibiotics and emergent consultation with a hand surgeon for incision and drainage are mandated with pyogenic flexor tenosynovitis.
S aureus is the most common organism, but Streptococcus as well as gram-negative and anaerobic organisms may occur.
The most specific sign of tenosynovitis is pain with passive digit extension.
Patients with immunocompromised states or recently administered antibiotics may not exhibit the classic tetrad of Kanavel signs.
Palpable crepitus may be present in flexor tenosynovitis.
Intersection syndrome can be diagnosed by palpable crepitus with wrist flexion/extension over the distal third of the dorsal forearm.
Inflammatory Flexor Tenosynovitis. The forefinger exhibits redness, uniform swelling, pain to palpation along the flexor sheath, and pain with passive extension. (Photo contributor: Lawrence B. Stack, MD)
Kanavel Signs. (Adapted from EM in 5. https://emin5.com/)
de Quervain Tenosynovitis. Swollen and markedly tender area over radial styloid in de Quervain tenosynovitis. (Photo contributor: Robert Tubbs, MD.)
Finkelstein Test for de Quervain Tenosynovitis. Pain over the radial styloid is elicited with ulnar deviation of the wrist as shown.