Tenosynovitis

Dr. Diyar A. SalihPlastic surgery resident

June, 2010 Kurdistan, Sulaimani

Tendonitis: Tendon

Tenosynovitis: Tendon + Synovium

1) Mesenchymal syndrome: multiple area of inflammation & tenosynovitis

Features

SleepSize discrepancy

Repetitive motion

Diagnosis

1) Pain at the wrist (specific comp), exacerbated by wrist movement.

2) Tenderness on examination.3) Grip strength decreased.4) Complete pain relieve by a small

amount of LA agent injection in to the compartment.

Treatment1) Conservative: for the first occurrence:

Modification of activities & avoiding heavy loading Steroid injection (into the involve sheath) Splinting (short term pain Mx) Elastic bands (esp. Tennis elbow) NSAID

2) Surgical: Synovial sheath decompression Size reduction Tendon rerouting through another compartment Postoperative splinting for 2 weeks & elevation

Triamcinolone 3-4 mgNo systemic or minimal local SENo more than 2 injection into the same areaIf the first injection failed to resolve the symptoms, there is no indication for the second injection (consider surgery)Avoid high dose:

1) Soft tissue atrophy2) Skin pigment disturbance

Trigger finger

A1

Painful nodule

Abrupt motion (Triggering)Usually painful

1) Under LA2) Pneumatic cuff3) Minimal dissection4) A2 pulley & NVB preserved5) Confirmed by Pt to flex digit6) Transverse incision: higher complication7) Index finger: radial side incised8) FPL: Transverse incision (preserve radial digital

nerve)

Congenital Trigger thumb

Notta node:Pathological thickening of FPL at MCPJ

Rx:1) Conservative: monitoring

up to 6 month of age.2) Spontaneous resolve

(some cases) 3) Surgical:

FPL tendon release through transverse incision at MCPJ

A1 pulley released No tendon size

reduction is attempted.

De Quervain tenosynovitis

1st Ext. compEPB

APL

There is a high degree of anatomical variation in the position of & no. of APL tendon, it is common to find separation of APL & EPB tendon by a septum.

Radial side pain

Finklestein test

Performed in steps:1. Ulnar deviation of the wrist2. Passive adduction of CMCJ3. Passive flexion of MCPJ 1

2

3

1st compartment surgical release

Intersection syndrome

ECRL

ECRB

1) Conservative: Modification of activities & avoiding heavy loading Steroid injection (into the involve sheath) Splinting (wrist in mild extension)

2) Surgical: Second dorsal compartment synovial sheath

decompression Postoperative splinting for 2 weeks (wrist in moderate

extension) & elevation

EPL tendonitis

3rd comp

Lister tubercle

Increased friction & tendonitis

ECU tendonitis

Ulnar sided wrist pain

Triangular fibrocartilage complex

ECU tendonitis

If conservative failed:Surgical Rx:1) Preserve volar

support2) ECU size reduction3) Rerouted through

fourth ext. compartment.

FCU tendonitis

Sharp curve over ridge of Trapezium

Trapezium ridge

Causes of pain in this site:1) Undetected scaphoid

fracture2) Basilar joint arthritis3) Ganglion cyst

Treatment:1) Conservative2) Surgical (synovial

sheath release)

Palmar cutaneous branch of median nerveRuns along flexor carpi radialis

Degenerative arthritis & bone spur formation ??

Lateral epichondylitis(Tennis elbow)

Burned out tendonitis

DxRx: often resolve with time.

1) Conservative: including elastic band at the border of the proximal and middle third of the muscle.

2) Surgical: weakening & tearing

of ECRB origin. ECRB origin &

periosteum excised (if replaced by granulation tissue as a result of chronic or recurrent inflammation).

ECRB

Power grip reduced

Lateral epichondylitis(Tennis elbow)

Radial nerve compression may coexist

Not limited to Tennis players

Surgical: 1) tearing & weakening of ECRB origin2) Excision: granulation tissue.

Medial epichondylitis

Pronator-flexor mass origin

DxRx:

1) Conservative2) Surgical:

weakening & tearing of PT-flexor mass origin.

Origin & periosteum excised (if replaced by granulation tissue as a result of chronic or recurrent inflammation).

Ulnar nerve protected.

Cubital tunnel syndrome

Coexist & differentiate from

Thank you