Rosen & Barkin's 5-Minute Emergency Medicine Consult (703 page)

• Definition
  
  • Inflammation of the tendon and tendon sheath
    
• Caused by inflammation, overuse, or infection
  
• Synovial sheaths cover tendons as they pass through osseofibrous tunnels:
  
  • Visceral and parietal layers of the synovium lubricate and nourish the tendons.
    
  • Infection can be introduced into tendon sheath.
    
• Skin wound
  
• Hematogenous spread
  
• Flexor tenosynovitis (FTS) of hand:
  
  • Typically infectious etiology
    
  • Penetrating injury especially at flexion creases of the finger is the most common mechanism.
    
  • High-pressure “injection” injury to fingers
    
• Air tools
  
• Paint sprayers
  
• Hydraulic equipment
  
• May appear minor on the surface but are associated with high incidence of FTS
  

• De Quervain tenosynovitis:
  
  • Caused by overuse
    
  • Inflammatory in nature
    
  • 2 thumb tendons: The abductor pollicis longus (APL) and extensor pollicis brevis (EPB).
    
  • On their way 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
    
• GC tenosynovitis:
  
  • Neisseria gonorrhea
    
• 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
    

DIAGNOSIS

• Cardinal signs of Kanavel for FTS include:
  
  • Tenderness and symmetric swelling along flexor tendon sheath (sausage digit)
    
• Flexed position of the digit
  
• Pain with passive extension of the finger
  
• Pain with palpation along the tendon sheath
  

• De Quervain tenosynovitis:
  
  • Repetitive pinching motion of thumb and fingers
    
• Assembly-line workers
  
• Carpenters
  
• Landscaping or weeding
  
  • Pain in the radial aspect of the wrist becomes worse with activity and better with rest.
    
  • Pain occurs on palpation along the radial aspect of the wrist.
    
  • Pain occurs with passive range of motion of the thumb.
    
  • Finkelstein test:
    
    • Pain occurs with ulnar deviation of the wrist with the thumb cupped in a closed fist.
      
• GC tenosynovitis:
  
  • 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
    

Traumatic tenosynovitis is seen after a direct blow to the lower portion of the forearm.

• Stenosing tenosynovitis:
  
  • Commonly seen at the inferior retinaculum of the peroneus tendon
    
  • Patients are usually >40 yr old and have some predisposing trauma.
    
  • Motion increases the pain.
    
• Rheumatoid tenosynovitis:
  
  • Medially, the posterior tibial and flexor hallucis longus tendons are commonly involved.
    
  • Laterally, the peronei are involved.
    
  • Anteriorly, the anterior tibial tendon is involved.
    
  • Motion increases the pain.
    
  • Spontaneous rupture may occur.
    

• Assess for infectious etiology:
  
  • History of sexually transmitted disease exposure, penile or vaginal discharge
    
• Obtain history of mechanism:
  
  • High-pressure injections
    
  • Puncture wounds, bites
    
  • Environmental exposures
    
• Assess tetanus status and comorbid factors (e.g., diabetes and immunocompromised).
  

• Assess Kanavel signs.
  
• Document neurovascular status.
  
• Tubular swelling of the tendon sheath if acute tenosynovitis is present.
  
• Identify signs and symptoms of systemic illness as well as other potential sites of infection.
  

Thorough history and physical exam will often lead to appropriate diagnosis.

• CBC, ESR:
  
  • May be of assistance in infectious etiology
    
• GC cultures (urethra, cervix, rectum, or pharynx) may be useful.
  
• Liver function tests may be elevated with disseminated
  N. gonorrhea
  infection.
  

• Radiographs are low yield, unless a retained radiopaque soft tissue foreign body is suspected.
  
• MRI has proven accurate in assisting the diagnosis of tenosynovitis:
  
  • Generally unnecessary in ED
    

NA

• Ankle, soft tissue injuries
  
• Bursitis
  
• Carpal tunnel syndrome
  
• Cellulitis
  
• Compartment syndrome
  
• Endocarditis
  
• Felon
  
• Gonorrhea
  
• Gout and pseudogout
  
• Hand infections
  
• High-pressure hand injuries
  
• Soft tissue hand injuries
  
• Soft tissue knee injuries
  
• Reiter syndrome
  
• Rheumatic fever
  
• Rheumatoid arthritis
  

TREATMENT

• Delay to definitive treatment leads to significant increased morbidity and loss of function.
  
• Elevation and immobilization of the affected extremity should be performed.
  

• Manage airway and resuscitate as indicated:
  
  • Septic shock
    
• Elevation, immobilization of affected extremity
  
• IV access
  
• Tetanus status
  
• Procedure
  
  • Diagnostic arthrocentesis is indicated if joint effusion is present with tenosynovitis:
    
    • Most patients with disseminated GC infection have coexisting septic arthritis.
      
    • Cultures are negative in 50% of patients.
      
    • 25% GC arthritis is polyarticular.
      
    • Joint fluid glucose is normal.
      
    • WBCs usually are <50,000 and a Gram stain is positive in 25% of the patients.
      

• High-pressure injection injuries to hand:
  
  • Surgical emergency
    
  • Immediate hand surgery consultation
    
  • Pain management
    
• Infectious FTS of hand:
  
  • Immediate hand surgery consultation
    
  • Broad-spectrum antibiotic coverage
    
• De Quervain tenosynovitis:
  
  • Rest, NSAID agents, and thumb spica splint
    
  • Consider lidocaine/corticosteroid injection if condition is unresponsive.
    
  • Phonophoresis (application of hydrocortisone gel to the radial styloid area daily) helps relieve pain in minor cases.
    
• GC tenosynovitis:
  
  • Admit for IV antibiotic therapy.
    
  • Penicillin or 1st-generation cephalosporins for initial therapy
    
  • 2nd-generation cephalosporins as an alternative
    
  • Surgical drainage may be indicated if antibiotics do not improve the condition.
    
  • Pain management
    
• Nongonococcal infectious tenosynovitis:
  
  • If diagnosis is equivocal, the patient should receive IV antibiotic therapy and consultation with a hand surgeon.
    
  • Cover for
    Staphylococcus
    ,
    Streptococcus,
    as well as anaerobic bacterial infection.
    
  • Consider coverage for
    Pseudomonas
    for the diabetic or immunocompromised patient.
    
  • Aminoglycosides may be added for double coverage.
    
  • Pain management
    

• Traumatic tenosynovitis:
  
  • Rest, ice, elevation, immobilization
    
  • NSAIDs
    

• Stenosing tenosynovitis:
  
  • Rest, ice, elevation, immobilization
    
  • NSAIDs
    
• Rheumatoid tenosynovitis:
  
  • Rest, ice, elevation, immobilization
    
  • NSAIDs
    

• Cefazolin: 1–2 g IV q8h (peds: 50–100 mg/kg/d IV div. q8h)
  
• Cefotetan: 1–2 g IV q12h (peds: 50–100 mg/kg/d IV div. q12h)
  
• Cefoxitin: 1–2 g IV q8h (peds: 80–160 mg/kg/d IV div. q6–8h)
  
• Ceftriaxone: 1–2 g IV q12h (peds: 50–100 mg/kg/d IV div. q12h)
  
• Clindamycin: 600–900 mg IV q8h (peds: 20–40 mg/kg/d div. q8h)
  
• Penicillin G: 12–24 mIU IV div. q4–6h (peds: 100,000–400,000 IU/kg/d IV div. q4–6h)
  
• Timentin: 3.1 g IV q6h (peds: 200–300 mg/kg/d IV div. q4–6h)
  
• Tobramycin: 1 mg/kg IV q8h or 5 mg/kg IV q24h (peds: 2–2.5 mg/kg IV q8h)
  
• Zosyn: 3.375 g IV q6h (peds: 200–400 mg/kg/d IV div. q6–8h)
  

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