What is the management for tenosynovitis of the flexor tendon on the volar aspect of the left thumb?

Management of Tenosynovitis of the Flexor Tendon on the Volar Aspect of the Left Thumb

The management of flexor tenosynovitis of the thumb should begin with conservative measures including NSAIDs, rest, splinting, and corticosteroid injections, with surgical intervention reserved for cases that fail to respond after 3-6 months of appropriate conservative treatment. 1

Initial Assessment and Conservative Management

First-line Treatment

• Pain Management:
  • NSAIDs are strongly recommended as first-line treatment for tendon pain 1
  • Ibuprofen 1.2g daily (safest option), can be increased to 2.4g daily if needed
  • Can be combined with paracetamol (up to 4g daily) for inadequate relief

Physical Interventions

• Rest and Activity Modification:

  • Elevation of the affected thumb to reduce swelling and accelerate healing 2
  • Avoidance of activities that exacerbate symptoms
  • Daily stretching exercises and gentle submaximal exercises 1

• Splinting:

  • Night splinting to maintain range of motion and prevent flexor contracture 1
  • Resting splints to prevent hypoextensibility in the flexor tendons

Corticosteroid Injections

• Local corticosteroid injections are highly effective for flexor tenosynovitis 3
• Studies show resolution of symptoms in 61% of cases after a single injection, with nearly 90% effectiveness when including repeated injections 3
• Recommended protocol:
  • Depo-methylprednisolone acetate or triamcinolone acetonide
  • Limit to 2-3 injections with 4-6 weeks between injections 1
  • Monitor for potential side effects (pain at injection site, stiffness, ecchymosis, or subcutaneous fat atrophy) 3

Rehabilitation Protocol

Phased Approach

1. Initial Phase (0-4 weeks):

   • Focus on pain control and protected range of motion 1
   • Gentle passive and active range of motion exercises

2. Intermediate Phase (4-8 weeks):

   • Progressive strengthening exercises 1
   • Gradually increase activity as tolerated

3. Advanced Phase (8-12 weeks):

   • Occupation-specific training and functional hand exercises 1
   • Return to full activity when:
     • Complete resolution of pain
     • Full range of motion
     • Strength symmetry >90% compared to uninjured side

Monitoring and Follow-up

• Regular assessment at 2,6, and 12 weeks to evaluate:
  • Pain levels
  • Range of motion
  • Functional improvement 1
• Consider imaging (MRI or ultrasound) for persistent symptoms 2, 1
  • MRI is ideal for evaluating tendon injuries and surgical planning 2
  • Ultrasound allows for visualization of tenosynovitis with enhanced vascularity 2

Indications for Surgical Referral

Consider surgical consultation if:

• Pain persists despite 3-6 months of well-managed conservative treatment
• Functional limitations significantly impact quality of life
• Progressive joint degeneration is evident on follow-up imaging 1

Special Considerations

Infectious Tenosynovitis

• If pyogenic flexor tenosynovitis is suspected (presence of Kanavel signs, history of penetrating trauma), urgent treatment is required 4, 5:
  • Intravenous antibiotics
  • Possible surgical debridement
  • Early antibiotics alone may be sufficient in cases with shorter duration of symptoms and fewer Kanavel signs 4

Common Pitfalls to Avoid

1. Misdiagnosis: Flexor tenosynovitis can be confused with other conditions like trigger finger or arthritis. Proper clinical examination supplemented by ultrasound can confirm diagnosis 2

2. Delayed Treatment: Early intervention is crucial to prevent progression to chronic tenosynovitis, which may lead to decreased hand function and quality of life 1

3. Inadequate Follow-up: Regular monitoring is essential to assess response to treatment and make timely adjustments to the management plan 1

4. Overlooking Infectious Causes: Always consider and rule out infectious tenosynovitis, especially with history of trauma, as this requires more aggressive management 4, 5

By following this structured approach to management, most cases of flexor tenosynovitis of the thumb can be effectively treated, preserving hand function and improving quality of life.