What is the treatment for flexor tenosynovitis?

Treatment of Flexor Tenosynovitis

For flexor tenosynovitis, treatment should begin with conservative measures including relative rest, activity modification, splinting, and NSAIDs, followed by corticosteroid injections if symptoms persist, with surgical intervention reserved for refractory cases or infectious tenosynovitis requiring immediate surgical drainage and antibiotics. 1

Types and Initial Approach

Flexor tenosynovitis can be categorized into several types, each requiring specific treatment approaches:

Non-Infectious Tenosynovitis

1. Conservative Management (First-line) 1

   • Relative rest and activity modification
   • Thumb spica splinting (especially for De Quervain's tenosynovitis)
   • NSAIDs for short-term pain relief (1-2 weeks)
   • Cryotherapy (ice application for 10-minute periods through a wet towel)
   • Physical or occupational therapy (eccentric strengthening exercises, tendon gliding exercises)

2. Corticosteroid Injections (Second-line) 1, 2

   • Highly effective with resolution in 61% of cases after a single injection
   • Can be repeated for recurrent episodes (effective in ~90% of cases overall)
   • Should be performed with ultrasound guidance when possible
   • Local adverse reactions (pain, stiffness, ecchymosis, fat atrophy) are typically self-limited

3. Surgical Management (For refractory cases) 1

   • Consider if symptoms persist beyond 4-6 months of conservative therapy
   • Indicated when there is evidence of muscle atrophy or severe functional limitations
   • Surgical release techniques are highly effective for persistent cases

Infectious (Pyogenic) Flexor Tenosynovitis

1. Immediate Treatment Required 3, 4

   • Prompt administration of empirical intravenous antibiotics
   • Early cases may be managed with antibiotics alone (under close supervision)
   • Surgical drainage and irrigation often necessary for established infections

2. Surgical Options for Infectious Cases 3, 5

   • Closed continuous irrigation with sterile saline or antibiotic solution
   • Open debridement and irrigation for severe cases
   • Innovative approaches include continuous irrigation with lidocaine solution to allow pain-free movement and early mobilization

Treatment Algorithm

Step 1: Initial Conservative Management (1-4 weeks)

• Relative rest and activity modification
• Splinting (especially at night)
• NSAIDs (oral or topical) for 1-2 weeks
• Ice application for pain relief
• Physical therapy with specific exercises

Step 2: If Symptoms Persist (4-8 weeks)

• Corticosteroid injection into the tendon sheath
• Continue splinting and activity modification
• Monitor for 2-4 weeks for response

Step 3: For Recurrent or Persistent Cases

• Consider repeat corticosteroid injection (if first injection provided temporary relief)
• Continue conservative measures
• Monitor for improvement

Step 4: Refractory Cases (symptoms beyond 4-6 months)

• Surgical consultation for tendon sheath release
• Post-surgical rehabilitation program

Special Considerations for Infectious Tenosynovitis

• Immediate IV antibiotics
• Surgical drainage if Kanavel's signs present (finger held in flexion, symmetric swelling, tenderness along tendon sheath, pain on passive extension)
• Consider closed continuous irrigation techniques
• Early mobilization when possible to prevent adhesions

Monitoring and Follow-up

• Regular assessment of symptoms and range of motion
• Ultrasound monitoring can help assess treatment response
• Early detection and intervention are crucial to prevent complications like erosive progression and permanent contractures 1

Cautions and Pitfalls

• Avoid continuous splinting during the day unless specifically indicated, as this can lead to muscle deconditioning 1
• Be aware that tenosynovitis may be an initial manifestation of systemic conditions like rheumatoid arthritis or lupus 6
• For infectious tenosynovitis, delayed treatment can result in significant morbidity including digit amputation 3
• Corticosteroid injections carry small risks of tendon rupture, though this is rare when properly administered 2

By following this structured approach, most cases of flexor tenosynovitis can be effectively managed with good functional outcomes and minimal complications.