(See also Bursa, Muscle, and Tendon Disorders: Tendinitis and Tenosynovitis)
Although the digital flexor tendons and extensor pollicis brevis are commonly affected, tenosynovitis may involve any of the tendons in or around the hand.
Digital Flexor Tendinitis and Tenosynovitis
Digital flexor tendinitis and tenosynovitis are inflammation, sometimes with subsequent fibrosis, of tendons and tendon sheaths of the digits.
These conditions are idiopathic but are common among patients with RA or diabetes mellitus. Repetitive use of the hands (as may occur when using heavy gardening shears) may contribute. In diabetes, they often coexist with carpal tunnel syndrome and occasionally with fibrosis of the palmar fascia. Pathologic changes begin with a thickening or nodule within the tendon; when located at the site of the tight first annular pulley, the thickening or nodule blocks smooth extension or flexion of the finger. The finger may lock in flexion, or “trigger,” suddenly extending with a snap.
Treatment of acute inflammation and pain includes splinting, moist heat, and anti-inflammatory doses of NSAIDs (see Joint Disorders: NSAIDs). If these measures fail, injection of a corticosteroid suspension into the flexor tendon sheath, along with splinting, may provide safe, rapid relief of pain and triggering. Operative release can be done if corticosteroid therapy fails.
De Quervain's Syndrome
De Quervain's syndrome is stenosing tenosynovitis of the short extensor (extensor pollicis brevis) and long abductor tendon (abductor pollicis longus) of the thumb within the first extensor compartment.
De Quervain's syndrome usually occurs after repetitive use (especially wringing) of the wrist, although it occasionally occurs in association with RA. The major symptom is aching pain at the wrist and thumb, aggravated by motion. Tenderness can be elicited just proximal to the radial styloid process over the site of the involved tendon sheaths. Diagnosis is highly suggested by the Finkelstein test. The patient adducts the involved thumb into the palm and wraps the fingers over the thumb. The test is positive if gentle passive ulnar deviation of the wrist provokes severe pain at the affected tendon sheaths.
Rest, warm soaks, and NSAIDs may help in very mild cases. Local corticosteroid injections and a thumb spica splint help 70 to 80% of cases. Tendon rupture is a rare complication of injection and can be prevented by confining infiltration to the tendon sheath and avoiding injection of the corticosteroid into the tendon. Intratendinous location of the needle is likely if injection is met with moderate or severe resistance. Surgical release of the first extensor compartment is very effective when conservative therapy fails.
Last full review/revision March 2008 by David R. Steinberg, MD