What is the initial treatment for tenosynovitis in the Emergency Room (ER)?

Initial Treatment of Tenosynovitis in the Emergency Room

The initial treatment for tenosynovitis in the emergency room should include NSAIDs as first-line medication, along with rest, ice, compression, and elevation (RICE protocol), with consideration for corticosteroid injection in moderate to severe cases. 1

Diagnosis Confirmation

• Clinical examination is the primary method for detecting synovitis and tenosynovitis 2
• In doubtful cases, ultrasound or MRI can help confirm the diagnosis 2, 1
• Hand flexor or extensor tenosynovitis on imaging may be a specific marker for rheumatoid arthritis 2

Treatment Algorithm

Step 1: Initial Management (First 24-48 hours)

1. NSAIDs:

   • Ibuprofen 400-800mg every 4-6 hours as needed for pain 1, 3
   • Can be increased up to 2400mg daily if needed 3
   • Should be taken with food to minimize GI side effects 3

2. RICE Protocol 1:

   • Rest: Avoid activities that exacerbate symptoms
   • Ice: Apply for 15-20 minutes every 2-3 hours
   • Compression: Use elastic bandage to reduce swelling
   • Elevation: Keep affected area elevated when possible

3. Splinting:

   • Immobilize the affected tendon in a functional position 1, 4
   • Splint should be worn continuously initially, except during gentle range of motion exercises

Step 2: Moderate to Severe Cases

1. Corticosteroid Injections:

   • Consider for moderate to severe pain or if no improvement with initial measures 1, 5
   • Prednisone is indicated for acute nonspecific tenosynovitis 6
   • Local injection with methylprednisolone or triamcinolone may provide relief in up to 61% of cases after a single injection 5
   • Limit to 2-3 injections with 4-6 weeks between injections 1

2. Antibiotics:

   • Required if pyogenic (infectious) tenosynovitis is suspected 7
   • Empiric broad-spectrum coverage pending culture results

Step 3: Additional Considerations

1. Physical Modalities (if available in ER):

   • Therapeutic ultrasound may provide additional benefit 8
   • Low-level laser therapy has shown efficacy in some studies 8

2. Patient Education:

   • Explain the condition and importance of adherence to treatment
   • Discuss activity modification to prevent recurrence

Special Considerations

Infectious Tenosynovitis

• Requires urgent surgical consultation for possible irrigation and debridement 7, 9
• Signs of infection include:
  • Rapidly progressive symptoms
  • Erythema, warmth, fever
  • Purulent discharge
  • Systemic symptoms

Rheumatoid Tenosynovitis

• May require more aggressive anti-inflammatory approach 2, 1
• Consider early rheumatology referral if multiple joints are involved or if systemic symptoms are present 2

Follow-up Recommendations

• Arrange follow-up within 1-2 weeks
• If no improvement after 3-4 weeks of conservative management, consider:
  • Repeat imaging
  • Specialist referral (rheumatology or orthopedic hand surgery)
  • Alternative diagnoses

Common Pitfalls

• Failing to distinguish between infectious and non-infectious tenosynovitis
• Inadequate pain control leading to poor compliance with therapy
• Prolonged immobilization leading to stiffness and decreased function
• Missing underlying systemic inflammatory conditions
• Overuse of corticosteroid injections, which can lead to tendon weakening or rupture

By following this structured approach, emergency physicians can effectively manage tenosynovitis while minimizing complications and promoting optimal recovery.