DKP2

Muhammad Alif Sayyidinoor

.Mahasiswa dapat mengetahui dan menjelaskan tentang
Tenosynovitis
a. Definisi
b. Klasifikasi
b. Gejala klinis
c. Etiologi
d. Epidemiologi :
e. Faktor risiko
f. Prognosis
g. Patofisiologi
h. Komplikasi
i. Tata Laksana
j. Pencegahan
k. Edukasi
2. Mahasiswa dapat menjelaskan secara singkat mengenai
diagnosis banding
3. Mahasiswa dapat menginterpretasikan data tambahan
Pengertian
Tenosynovitis refers to inflammation of a tendon and its synovial sheath; this condition
occurs most frequently in the hand and wrist but can occur in any part of the extremities
where a tendon glides within a synovial-lined fibro-osseous sheath.
Klasifikasi
Faktor Risiko
 Epidemiologi
Infectious Tenosynovitis:
•Accounts for 2.5-9.4% of all hand infections.
•Higher possibility of concomitant infection when
there's evidence of tendon sheath inoculation.
•Hematogenous spread is limited but reported cases
include disseminated gonococcal infection (DGI).
•DGI more commonly leads to septic arthritis (about
40% of cases), with rare instances of septic arthritis
and tenosynovitis without prior dissemination.
Idiopathic or Stenosing Tenosynovitis (Trigger Finger and
De Quervain Tenosynovitis):
•Trigger finger has a prevalence of 2% in the general
population, increasing significantly in individuals with diabetes.
•Bimodal distribution with peaks in childhood and middle age.
•Female predilection in adults; ring finger most commonly
affected.
•De Quervain tenosynovitis historically reported in lactating
mothers.
•Incidence of De Quervain tenosynovitis is 0.94 per 1000
person-years.
•Risk factors for development include female sex, age >40
years, and black race.
and affect gliding.
Epidemiologi
Inflammatory Tenosynovitis (Rheumatoid Arthritis and
Psoriatic Arthritis):
•Rheumatoid arthritis (RA) often involves the tendon sheath.
•About 55% of RA patients report symptoms of tenosynovitis,
affecting an average of 3.1 tendons.
•Radiographic evidence of tenosynovitis on MRI is found in up
to 87% of RA patients.
•Psoriatic arthritis prevalence among psoriasis patients is 6-
41%.
•Tenosynovitis suggested as a transition between psoriasis and
psoriatic arthritis.
•Crystalline deposition disorders rarely involve true tendon
involvement, but tophi and osteophytes can irritate tendons and
affect gliding.
Fisiologi
Fisiologi
Fisiologi
Patofisiologi
Inflammatory Increased
Initial Trigger
Response Blood Flow

Synovial
Tendon Synovial Fluid
Membrane
Irritation Changes
Involvement

Impaired
Adhesions and Chronic
Tendon
Fibrosis Inflammation
Function
 Prognosis
Prognosis of Infectious Tenosynovitis:
•Favorable Prognosis: Early cases of infectious tenosynovitis in healthy patients generally have a favorable prognosis.
•Increased Risk for Complications: Fulminant infection, chronic infection, and impaired immune status increase the risk of long-term complications and
impairment.
•Common Complications:
• Digit Stiffness: Most common complication due to adhesions. Tenolysis considered if loss of functional motion persists.
• Soft-Tissue Necrosis: More common in delayed presentation or patients with diabetes. May lead to amputation if the digit becomes
nonfunctional, stiff, and painful.
•Factors Associated with Poor Outcome:
• Presence of diabetes mellitus
• Late presentation
• Association with a human bite
•Risk Factors for Amputation:
• Age >43 years
• Presence of diabetes mellitus, renal failure, or peripheral vascular disease
• Ischemic changes at presentation
• Subcutaneous purulence
• Polymicrobial infections
•Prognosis and Ischemia: Prognosis closely related to the presence of digital ischemia. Without ischemic changes, amputation is rare.
•Active Range of Motion (ROM):
• Total active ROM: 72% vs. 80%, based on presence of subcutaneous purulence.
• Those with both purulence and ischemic change underwent amputation in 59% of cases, recovering only 49% of total active ROM.
 Gejala Klinis
General Considerations:
•History and examination guide differential diagnosis.
•Acute cases like pyogenic flexor tenosynovitis (PFT) and gout
often seen in the emergency department (ED); indolent or
progressive cases in clinic.
•Thorough history needed, including handedness, occupation,
vocation, functional status.
Infectious Tenosynovitis:
•Patients may report trauma (puncture wound, laceration, bite) or
progressive pain, swelling, stiffness, and erythema along affected
finger.
•Fever is infrequent (17%).
•Gonococcal flexor tenosynovitis common in sexually active
teens, young adults; more in women during pregnancy or
menstruation.
•Features include rapid onset from sexual exposure, absent
vaginal/penile discharge, fever, chills, malaise, and joint pain.
Idiopathic or Stenosing Tenosynovitis (Trigger Finger and
De Quervain's Tenosynovitis):
•Trigger finger: Early cases have painless clicking with passive
digit motion, which improves through the day. Progression
leads to painful catching or locking of digit, requiring passive
extension.
•De Quervain's tenosynovitis: Pain along thumb radial wrist,
worse with power grip and weightbearing. Swelling near radial
styloid. Afflicts new mothers lifting newborns.
Inflammatory Tenosynovitis:
•Presents more indolently than infectious tenosynovitis;
sometimes mimics infection.
•Symptoms include digital stiffness, swelling, and triggering.
•Erythema may be present with acute inflammatory response.
•Gout can cause severe symptoms like malaise or low-grade
fever.
Diagnosis
Approach
Complete History Check
Physical Examination
Additional Exam (Lab, Radiography)
Diagnosis
Physical Exam
Infectious Tenosynovitis:
•Patients with pyogenic flexor tenosynovitis (PFT) can present after
penetrating injury.
•Initial inspection may show erythematous, swollen digit. Guarding
hand due to tenderness.
•Kanavel signs include:
• Semiflexed digit at rest
• Uniform swelling of entire digit
• Tenderness along flexor tendon sheath
• Exquisite pain along volar surface with passive extension.
•These signs have sensitivity but lack specificity individually.
•Fusiform swelling seen in rheumatoid tenosynovitis, not in PFT.
•Gonococcal tenosynovitis: Common fever, dermatitis with
hemorrhagic macules/papules on extremities/trunk.
Idiopathic or Stenosing Tenosynovitis (Trigger Finger and De
Quervain's Tenosynovitis):
•Trigger finger: Replicate locking of affected finger. Nodule proximal to
A1 pulley may be palpated.
•De Quervain's tenosynovitis: Swelling at first dorsal compartment,
painful palpation.
•Eponymous tests for diagnosis: Finkelstein maneuver (wrist ulnar
deviation with thumb flexion) and Eichoff maneuver (fist with thumb
flexed, wrist ulnar deviation).
Inflammatory Tenosynovitis:
•Inflammatory flexor tenosynovitis often results from underlying
disease.
•Swelling common initial finding.
•Active flexion different from passive due to tissue expansion and
impingement.
•RA patients mostly involve small joints (MCP, PIP, MTP).
•Rheumatoid nodules may be present, tenosynovitis often involves
extensor tendons.
 Diagnosis
•Coagulation Studies:
Laboratory Studies:
• Needed in anticoagulated patients or those
•Complete Blood Count (CBC) with Differential:
with bleeding diathesis.
• WBC count generally normal in isolated hand
• Rule out disseminated intravascular
infections, may be elevated in progressive infection or
coagulation (DIC) in severe infections with
systemic involvement.
sepsis concern.
• Not elevated in nonsuppurative conditions or
•Rheumatoid Factor (RF):
immunocompromised patients.
• Test for RA consideration.
• Left shift often observed in acute processes.
•Blood Cultures:
•Erythrocyte Sedimentation Rate (ESR) and C-reactive
• If febrile or unstable, draw before starting
Protein (CRP):
antibiotics.
• Nonspecific inflammatory markers, monitored for
•Gonococcal Cultures:
treatment response.
• Appropriate if gonococcal tenosynovitis
• Often normal in closed-space hand infections.
suspected.
•Creatinine:
• Positive in around 80% of patients.
• Provides renal function information, affecting antibiotic
• Transiently elevated liver function studies
selection.
(LFTs) with disseminated gonococcal
infection.
Diagnosis
Aspiration and Evaluation of Joint Fluid:
•Aspiration of synovial fluid enables microbiologic and histopathologic analysis.
•Obtain culture and gram stain before starting definitive antibiotics, including
aerobic, anaerobic, fungal, AFB, and atypical AFB samples.
•Histopathologic analysis may reveal nonbirefringent crystals (gout) or birefringent
crystals (pseudogout).
•Diagnostic arthrocentesis needed for joint effusion with tenosynovitis due to
potential coexistent septic arthritis in disseminated gonococcal infection.
•Characteristics of aspirated fluid:
• Sterile fluid common in gonococcal arthritis; cultures negative in 50% of
patients.
• Joint fluid glucose usually normal.
• WBC counts usually below 50,000/μL.
• Gram stain positive in only 25% of patients.
Tatalaksana
Approach Considerations:
•Treatment for tenosynovitis depends on the underlying cause of inflammation.
•Nonoperative management often used for nonsuppurative tenosynovitis, while surgery may
be needed for chronic cases.
•Infectious tenosynovitis is an orthopedic emergency; surgical drainage is recommended.
•Medical treatment can be considered for early, uncomplicated infections, but prompt
improvement is necessary within 12 hours.
•Surgical management is needed for delayed or progressive infections.
•Various approaches to access the flexor tendon sheath described, providing wide exposure
or minimally invasive access.
•Wide exposure recommended for advanced infections (Michon stage III).
•Early diagnosis, small incision drainage, and postoperative irrigation associated with best
outcomes.
•Staphylococcus aureus commonly detected in purulent flexor tenosynovitis cases.
•For Mycobacterium infections, tenosynovectomy options vary between radical and partial,
with multiple antibiotic regimens and observation.
Tatalaksana
Idiopathic or Stenosing Tenosynovitis:
•Cessation of activity causing tenosynovitis is key.
•Treatment includes icing, elevation, NSAIDs, short-course oral steroids, corticosteroid injections,
splinting, and slow rehabilitation.
•Corticosteroid injections should be used carefully, especially in diabetes or inflammatory arthritis.
•Contraindicated if infectious tenosynovitis not ruled out.
De Quervain Tenosynovitis:
•Minimal symptoms treated with rest, NSAIDs, and splinting.
•Peritendinous lidocaine-corticosteroid injection preferred; surgery if conservative treatment fails.
Trigger Digits:
•Initial treatment with peritendinous lidocaine-corticosteroid injection.
•Activity modification, NSAIDs, and splinting considered.
•Surgical tendon release if injection fails, with high success rates.
Inflammatory Flexor Tenosynovitis:
•Nonoperative management is primary treatment.
•For persistent cases, flexor tenosynovectomy may be necessary.
•Rheumatoid inflammatory flexor tenosynovitis treated with ice, NSAIDs, rest, splinting,
hydroxychloroquine, gold, penicillamine, methotrexate.
•Corticosteroid injections for acute flares; limited to prevent tendon rupture.
Tatalaksana
Infectious Tenosynovitis:
•Prompt medical management can prevent immediate surgery.
•Nonoperative treatment includes synovial fluid aspiration, IV
antibiotics, elevation, splinting, and rehabilitation.
•Elevation and broad-spectrum antibiotics needed if diagnosis is
unclear.
•Surgical intervention warranted for immunocompromised or
diabetic patients.
•Inpatient observation if medical treatment attempted; surgical
drainage if no improvement in 12-24 hours.
•Gonococcal tenosynovitis requires IV or IM antibiotics;
surgical drainage if no improvement in 48 hours.
Tatalaksana
Tatalaksana
Stage I and II Infections:
•Recommended approach involves proximal and distal incisions for Idiopathic or Stenosing Tenosynovitis:
drainage and irrigation. •A1 pulley release for cases not suitable for steroid
•Proximal incision over A1 pulley; distal incision over A5 pulley. injection.
•Catheter inserted into tendon sheath through proximal incision. •Percutaneous approaches possible, but open approach
•Sheath irrigated with normal saline (500 mL minimum). preferred.
•Catheter removed or sewn loosely; small drain placed in distal •Small incision at MCP crease, A1 pulley completely
incision.
•Wounds left open, hand elevated, and empiric antibiotics started. sectioned.
•Continuous or intermittent irrigation techniques can be used. •Passive and active digit flexion to ensure full release.
Open Tendon Sheath Débridement: Inflammatory Tenosynovitis:
•Indications: Stage III infections, chronic infections, infections by •Extensive volar Brunner incisions for tenosynovectomy.
atypical mycobacteria. •Diseased tenosynovium excised; anular pulleys preserved.
•Incisions: Zigzag Brunner or longitudinal midaxial incision.
•Midaxial incision preferred due to postoperative coverage
concerns.
•Sheath exposed; incision dorsal to neurovascular bundle.
•Extensive infections may involve opening sheath at pulleys while
preserving anular pulleys.
•Copious irrigation, wounds left open with drains.
•Empiric antibiotics, dressings, and splinting.
•Reevaluation after 48 hours; repeat irrigation if infection not
controlled.