How is tenosynovitis treated in the hand in children?

Treatment of Tenosynovitis in the Hand in Children

The initial treatment for tenosynovitis in the hand in children should include a trial of scheduled NSAIDs and may include intraarticular glucocorticoid injections as part of initial therapy. 1

Treatment Algorithm

First-Line Treatment

1. NSAIDs (Nonsteroidal Anti-inflammatory Drugs)

   • Conditionally recommended as part of initial therapy 1
   • Should be scheduled rather than as-needed
   • Short-term use (typically 1-2 weeks) for pain relief 2
   • Consider topical NSAIDs for fewer systemic side effects in appropriate cases 2

2. Intraarticular Glucocorticoid Injections (IAGCs)

   • Conditionally recommended as part of initial therapy 1
   • No preferred steroid type for injection 1
   • Can resolve symptoms in approximately 61% of cases after a single injection 2, 3
   • Should be considered when NSAIDs alone are insufficient

3. Adjunctive Conservative Measures

   • Relative rest and activity modification 2
   • Splinting, especially at night 2
   • Cryotherapy (ice application for 10-minute periods through a wet towel) 2
   • Physical or occupational therapy including:
     • Eccentric strengthening exercises
     • Tendon gliding exercises
     • Ergonomic education 2

Second-Line Treatment (Inadequate Response to First-Line)

1. Conventional Synthetic DMARDs
   • Strongly recommended for inadequate response to or intolerance of NSAIDs and/or IAGCs 1
   • Methotrexate (MTX) is conditionally recommended as the preferred agent over leflunomide (LEF), sulfasalazine (SSZ), and hydroxychloroquine (HCQ) 1

Third-Line Treatment

1. Biologic DMARDs
   • Conditionally recommended for inadequate response to or intolerance of NSAIDs and/or IAGCs and at least one conventional synthetic DMARD 1
   • No preferred biologic DMARD has been identified 1

Special Considerations

Important Factors to Guide Treatment Decisions

• Consider risk factors for poor outcome, including:
  • Involvement of ankle, wrist, hip, sacroiliac joint, and/or TMJ
  • Presence of erosive disease or enthesitis
  • Delay in diagnosis
  • Elevated levels of inflammation markers
  • Symmetric disease 1

Monitoring and Follow-up

• Use validated disease activity measures to guide treatment decisions 1
• Regular monitoring of symptoms and range of motion is crucial to prevent long-term complications 2
• Early detection with ultrasound is important as tenosynovitis may predict erosive progression 2

Treatment Duration

• For infectious tenosynovitis, antimicrobial therapy may be required for extended periods 2
• For tenosynovitis associated with systemic conditions like juvenile idiopathic arthritis, treatment duration follows management of the underlying condition 2

Treatments to Avoid

• Oral glucocorticoids are conditionally recommended against as part of initial therapy 1
• Avoid continuous splinting during the day unless specifically indicated, as this can lead to muscle deconditioning 2

Diagnostic Tools for Monitoring Response

• Ultrasound can be valuable for confirming diagnosis and monitoring treatment response 2
• MRI without contrast may be considered for suspected nerve abnormalities 2

Surgical Considerations

• If tenosynovitis cannot be controlled by non-surgical means, tenosynovectomy can provide successful, long-term relief and prevent tendon ruptures 4
• Consider surgical referral if symptoms persist beyond 4-6 months of conservative therapy 2

Pitfalls and Caveats

• Potential problems with splinting include increased focus on the affected area, compensatory movement strategies, muscle deconditioning from immobilization, and increased pain in some cases 2
• Failure to treat underlying systemic conditions (like JIA) may lead to poor outcomes
• Delayed treatment may increase risk of tendon rupture or permanent damage
• Overreliance on oral glucocorticoids should be avoided as they are conditionally recommended against as initial therapy 1