From the Guidelines
Flexor tenosynovitis of the wrist should be initially treated with rest, ice, compression, and elevation (RICE) along with non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen 400-600mg three times daily or naproxen 500mg twice daily for 1-2 weeks. The symptoms of flexor tenosynovitis of the wrist include pain, swelling, and limited wrist function due to repetitive movements, direct trauma, or infection, causing the synovial sheath to thicken and restrict tendon movement.
Treatment Options
- A wrist splint should be worn in a neutral position for 2-3 weeks, especially during sleep and activities.
- Physical therapy focusing on gentle stretching and strengthening exercises is recommended once acute pain subsides.
- For persistent symptoms, corticosteroid injections (such as methylprednisolone 40mg with lidocaine) may be administered into the tendon sheath.
- Surgical release of the tendon sheath (tenosynovectomy) is considered for cases that don't respond to conservative treatment after 3-6 months, as surgery is an effective treatment option in carefully selected patients 1.
- Infectious tenosynovitis requires immediate medical attention with antibiotics (often a combination of cefazolin 1g IV every 8 hours and gentamicin 5mg/kg IV daily) and possible surgical drainage. The diagnosis of flexor tenosynovitis can be confirmed with MRI, which is useful for diagnosing infectious and noninfectious tenosynovitis in both the flexor and extensor wrist compartments 1.
Diagnostic Approach
- MRI (without or with IV contrast) or US are alternative initial examinations that are usually appropriate in this setting.
- Fluid-filled and synovial-lined structures (including ganglia, cysts, bursa, and tendon sheaths) are well depicted with MRI. It is essential to note that most patients with overuse tendinopathies (about 80 percent) fully recover within three to six months, and outpatient treatment should consist of relative rest of the affected area, icing, and eccentric strengthening exercises 1.
From the Research
Symptoms of Flexor Tenosynovitis
- The symptoms of flexor tenosynovitis include pain, swelling, and limited range of motion in the affected finger or wrist 2
- Kanavel's signs are commonly used to diagnose pyogenic flexor tenosynovitis, which include tenderness over the flexor tendon sheath, symmetrical swelling of the finger, and pain on extension of the finger 3
- Inflammatory markers may be elevated in patients with flexor tenosynovitis, indicating the presence of an infection 3
Treatment Options for Flexor Tenosynovitis
- Surgical treatment, including irrigation and debridement of the flexor sheath, is often necessary to evacuate the infection and prevent morbidity and loss of hand function 4, 2
- Conservative treatment with intravenous antibiotics may be considered for patients with uncomplicated pyogenic flexor tenosynovitis, under the surveillance of a hand specialist 3
- Physical modalities, such as ultrasound therapy, low-level laser therapy, and extracorporeal shock wave therapy, may be used as part of conservative treatment for flexor tenosynovitis, although more high-quality studies are needed to define evidence-based practice 5
- Immobilization, elevation, and antibiotics may be used to treat early infectious flexor tenosynovitis, with some patients achieving full return of hand function without surgical intervention 6