Tenosynovitis

hpi

This is 28-year-old female history of IV heroin abuse currently on Suboxone treatment who is coming in for 4 day history of progressively worsening right hand pain and swelling.  States one week ago hit her hand on a stapler with minimal trauma.  Several days later she then developed pain, swelling and redness over her fourth knuckle on her right hand.  The pain has been progressively worsening unresponsive to Tylenol and Motrin.  She is now unable to fully extend her fourth finger due to pain.  Denies any fevers, chills, nausea, vomit, diarrhea. Her history is significant for similar infection to her left hand requiring incision and drainage approximately 6 months ago. She is right-handed.  Smokes daily.

Physical exam

Exam:
There is significant swelling and erythema over the right fourth digit from the metacarpal joint to the PIP.  Appears "sausage-like ".  The right fourth finger is held in slight flexion.  Patient is unable to extend the finger fully.  With passive extension of the finger patient has significant pain.  Significant tenderness over the entire fourth digit. Sensation intact to light touch.

Radiographs:
There is no evidence of fracture dislocation.  Soft tissue swelling noted over the fourth finger

Laboratory data:
White blood cell count 9.7, sedimentation rate 10, C-reactive protein 2.6

DIanosis/ plan

Presentation consistent with tenosynovitis.  She was given IV antibiotics, evaluated by orthopedics at bedside. Taken to OR for I&D.

DIscussion

Tenosynovitis is an inflammation of a tendon and it is synovial sheath.  It most frequently occurs in the hands and wrists however can occur in any joint.  Tendon sheaths have 2 surfaces, a visceral layer (inner) and a parietal layer (outer).  When fluid and inflammatory markers accumulate between these two layers and their potential space, this is referred to as tenosynovitis.

There are 3 mechanisms that accounts for most episodes of tenosynovitis:
1.  Trauma (puncture wound, laceration)
2.  Contiguous spread from adjacent infected soft tissue
3.  Hematogenous

Organisms:
The most common pathogens are skin flora including Staphylococcus aureus and Streptococci. However, any organism can cause tenosynovitis.

Tenosynovitis is a clinical diagnosis.  There are four classic clinical findings as described by Kanavel: Tenderness over the entire flexor tendon sheath, symmetric finger swelling over the length of tendon sheath described as "sausage-digit", intense pain with passive extension, resting flexed posture of digit to minimize pain.  Often radiographs are obtained to rule out fracture or bony involvement.  Often these are normal.  No lab tests are sensitive or specific to tenosynovitis.

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pearls

Tenosynovitis is a clinical diagnosis
Recognize Kanavels four classic clinical findings
Broad spectrum antibiotics