Tenosynovitis

TENOSYNOVITIS* AN INDUSTRIAL JEWETT

V. REED,

M.D.

DISABILITY

AND

On staffs of the Methodist, St. Vincent’s and Indianapolis City Hospitals

ALLAN

K.

HARCOURT,

M.D.

On staffs of the Methodist, St. Vincent’s and IndianapoIis City Hospitals

INDIANAPOLIS,

W

‘ITH the speeding up of production in most types of work, it is obvious that it is the duty of the industria1 surgeon to do everything possibIe to reduce disabihty in injured workmen. In order to test the efliciency of some of our methods of treatment, we are anaIyzing various groups of cases in order to determine whether or not our methods can be improved. We have chosen the subject of tenosynovitis, a comparativeIy simpIe injury, but one that resuIts in a great variation in length of disabiIity. If we can determine why some patients recover in a few days whiIe others are disabIed for sixty days or more, apparentIy suffering from the same type and severity of trauma, we may be abIe to improve our method of treatment. During a recent twelve-month period we treated seventy persons with a diagnosis of tenosynovitis, approximateIy .54 per cent of the tota admissions for that period. The tota time Iost on account of disabiIity of these seventy persons amounted to 1,222 days, or approximateIy three and one-third years, a rather surprising amount of time lost for a comparativeIy minor injury. We divide our cases of tenosynovitis into three groups: first, those cases foIIowing strains of the wrist or ankIe in which the tendons are overstretched; second, contusions to the tendons and sheaths, both of which cIass&cations are considered as accidents; and third, a group which is becoming more common, in which irritation of the tendon and sheath foIIows repeated and rapid motion of the part, a condition which shouId be cIassed as an

INDIANA

occupationa disease. The above three types of tendon insuIt may occur in tendons apparentIy normaI, or they may be superimposed on a tendon or sheath which has some pre-existing abnormaIity, perhaps an abnormaIity that has been entireIy free from symptoms until some trauma or irritation brings it to the patient’s notice. The pathologica status of tenosynovitis has not been demonstrated as compIeteIy as many other conditions because we seldom have the opportunity to examine the affected parts unIess they require expIoration. It is easy to visuaIize, however, the pathoIogica1 picture occurring in a contused or overstretched tendon in which a few fibers may be torn, the presence of minute hemorrhage, edema and exudation producing more or Iess IocaI sweIIing. It is quite diffIcuIt, however, to visuaIize the changes which take pIace in a tendon or its sheath folIowing rapid or repeated motions. Moritz’ describes the work of OboIenskaja and GoIjanitzki in which they found in experimenta animaIs, fraying of the surfaces of both the tendon and its sheath, accompanied by edema and interstitia1 hemorrhage, foIIowing rapid, repeated motions of the tendon. These changes are probabIy the beginning of narrowing of the sheath or adhesions between the sheath and the tendon, which are found occasionaIIy on expIoration. Howard2 expIored three cases of crepitating tendons in order to study their pathoHe found that in certain IogicaI status. cases of direct bIows over the Ieg or forea crepitating sweIIing appeared. arm, ExpIoration showed a jeIIy-like edema

* From the IndianapoIis 392

IndustriaI

Clinic.

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about the muscIe-tendon junction, together with some muscIe fiber degeneration. The various Iatent abnormalities of tendons or their sheaths which may be aggravated by either trauma or repeated motions, are scar tissue changes, probabIy the resuIt of previous injuries, and neopIasms. The scar tissue changes consist of sIight sweIIings in the tendons, often accompanied by a constriction of the sheath at the corresponding Ievel. Again, fibrous bands may form between the tendon and its sheath. Tumors of the tendons and sheaths are quite rare. The most common of these is the fibroma, a true benign neopIasm. It may occur as a smaI1 round noduIe on, or within, the tendon. A fibroma is not the result of trauma but it can become noticeabIe foIlowing trauma or excessive motion. Some of the oIder texts describe tenosynovitis as being due to a “rheumatic This may be true in some condition.” instances but we have never seen a case in which we couId ascribe this etioIogy. It is possibIe, however, that a Iatent or cryptogenie infection, as of the teeth, sinuses, might prolong recovery or even etc., aggravate a traumatic tenosynovitis. A gangIion of a tendon sheath does not properIy come under the heading of NevertheIess, it is we11 to tenosynovitis. consider it at this point. We usuaIIy consider a gangIion as a hernia1 protrusion of the tendon sheath, a sweIIing which may appear spontaneousIy or may foIIow shortIy after an injury. Pack3 states that a gangIion is not a herniation of the sheath but is due to a fibropIasia and coIIoid degeneration which coaIesce to form a cyst. Regardless of their pathology, we must admit that many gangIia foIIow trauma to the tendons of the wrist. There are a few other forms of tendon disorders that may be mentioned but which were not encountered in the cases under consideration. At times these must be kept in mind in making a differentia1 diagnosis. There is the septic or pyogenic form of tendon sheath infection which foIIows infected wounds of the hands

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or wrists. RareIy we encounter tubercuIous tenosynovitis or gonorrhea1 tenosynovitis, neither of which has any reIation to trauma. The xanthoma is a noduIar mass occasionaIIy found on a ffexor tendon of one of the fingers. It is a granuIoma composed of various types of connective tissue ceIIs intermingIed with Iipoid materia1. These growths are benign and it is questionable whether or not they are true neoplasms. ApparentIy they have no reIation to trauma. In the form of tenosynovitis under consideration, that is, those cases resuIting contusions and repeated from strains, motions, pain, usuaIIy disabIing, in the region of the affected tendon is the most constant feature. This is made worse on pressure over the part and aIso on using the member controIIed by that tendon. SweIIing of the tendon sheath can often be seen and paIpated. It is unusua1 for the overIying skin to be reddened. In the majority of cases a tendon crepitation is marked and can either be feIt or heard through the stethoscope. OccasionaIIy, a cIicking or snapping sensation is present as the tendon passes through its sheath. This is a most important finding. When it is present in an acute case it means that the abnormaIity has existed prior to the trauma, perhaps causing no troubIe until aggravated by trauma or overuse. This cIicking or snapping is the result of a scar tissue thickening or a fibroma of the tendon, usuahy associated with a constriction of the tendon sheath. Often these nodules and thickenings of the tendon can be paIpated. In a few of our cases this cIicking sensation was not present during the acute stage of the troubIe but appeared Iater. This was probabIy due to an exudate within the sheath during the acute stage, which distended it to the point that the cIicking couId not be observed unti1 after the acute symptoms had subsided. The diagnosis of tenosynovitis offers no diffIcuIty if one finds the cIinica1 features enumerated above. That form of tenosynovitis folIowing the excessive use of a

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part has been confused with the so-caIIed occupationa cramps or paIsies. The chief differentia1 point is that in the case of an occupationa cramp, the pain or disabiIity occurs onIy when the patient is performing those motions required in his work. Making the same motions on examination causes no dificuIty. In the case of tenosynovitis, the pain is present on motion under a11 conditions. The treatment of acute tenosynovitis has been to put the part to rest by means of a pIaster spIint. This is removed about every second day in order to give the parts gentIe passive motion to prevent stiffness, and aIso for the appIication of a diathermy treatment. After the acute symptoms have subsided, the patient is aIIowed to use the part for very sIight movements onIy. When a11 pain has subsided the patient is aIIowed to resume his work graduaIIy. Permitting patients to return to work too soon has been the cause of recurrence in severa cases. When a cIicking or snapping is noted, exploration is performed as soon as possibIe. When a distinct noduIe is found, it is excised and the sheath repaired. When there is a fusiform sweIIing of the tendon with a constriction of the sheath, the Iatter shouId be “ windowed ” to aIIow free motion of its contained enIarged tendon. In our present study of seventy cases of tenosynovitis, forty-four were attributed thirteen to contusions and to strains, thirteen to repeated motions, such as pushing materia1 with the thumb and finger, repeated pressure on a part of a machine, turning screws, rubbing or poIishing materiaIs, etc. The forty-four cases of tenosynovitis due to strain are distributed as foIIows: Extensors of the wrist or fingers at the Ievel of the wrist.. 32 FIexors of the wrist. . 2 Extensors of the thumb.. 4 Extensors of the index finger.. 2 Flexor of the index finger. I Extensors of the toes.. I Tendo caIcaneus.. . 2

(WhiIe the tendo caIcaneus possess a sheath, when strained

does not and con-

DECEMBER,

,943

tused it can produce the same cIinica1 features as sheathed tendons. Even crepitation is generaIIy present.) Out of this group of tenosynovitis due to strains, two patients were operated upon. CASE W.

REPORTS

R., a maIe, age twenty-nine,

strained his

right wrist. After a few days the condition gave the appearance of a tenosynovitis of one of the flexors in the right wrist. With rest to the part the condition improved, but on returning to work the pain returned. Over a period of about three months he had thirteen days of disabihty and when working he had to Iimit his activities. During the fourth month foIIowing the injury a smaI1 nodule couId be palpated on a tendon in the wrist proximal to the ffexor retinacuIum. This was expIored and proved to be a true fibroma in the flexor indicis profundus tendon. Forty-four days foIIowing the operation he returned to work, free from symptoms. His Iong convalescence was occasioned by the necessity of severing the tendon and repairing it in the remova of the fibroma. sprained the L. B., a femaIe, age thirty, extensor tendons of the Ieft thumb. She worked about one month without receiving treatment, and then splinting and diathermy treatment were used for fifty-six days with very IittIe improvement and she was stiI1 disabled. On account of the persistent pain and tenderness. the tendon of the extensor poIIicis brevis was expIored. A constriction of the sheath was found dista1 to the annuIar Iigament, with adhesions between the sheath and the tendon. The constriction was severed and the adhesions were broken up. The patient returned to work at. the end of twenty-five days, free from symptoms. The thirteen cases of tenosynovitis due to contusions can be grouped as foIIows: Extensors Extensors Flexors of Extensors

of the wrist.. of the fingers.. the fingers. of the ankle..

Out of this group, operated upon :

three

8 2 2 I

patients

were

F. L., a female, age thirty, had a contused Aexor surface of the right wrist. She was given conservative treatment with short periods of

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disabiIity for about one year when a gangIion appeared over the ffexor carpi radiaIis. FoIIowing remova of the gangIion she was abIe to resume work after thirty days. suffered a J. W., a maIe, age thirty-nine, contused paIm of the Ieft hand. The diagnosis of tenosynovitis of the flexors of the Ieft ring finger was made. After two weeks of conservative treatment there was no improvement. By this time the diffuse sweIIing which had appeared immediateIy after the injury, had subsided and a distinct noduIe in the tendon could be paIpated in the palm at the base of the finger. ExpIoration through the paIm revealed a true fibroma of the tendon sheath, which was removed. The patient returned to work in thirty-five days. P. J., a maIe, age thirty-three, contused and Iacerated the paImar surface of the Ieft wrist, not invoIving tendons or the Iaceration sheaths. Six weeks Iater he reported, complaining of a painful noduIe in the tendon of the Aexor carpi radiaIis in the middIe third of the forearm. Exploration reveaIed a smaI1 true fibroma of the tendon, which was removed, foIIowed by a reIief of symptoms. He returned to work five days foIIowing the operation. In the contusion this case, in al1 probability the pre-existing brought to his attention fibroma. The thirteen cases of tenosynovitis suiting from rapid or repeated motions grouped as foIIows:

reare

Extensors of the wrist or fingers at the level of the wrist. 7 Extensors of the thumb.. 3 FIexorsofthethumb................ 2 Flexor of the middIe finger in the paIm I

Out of this operated upon

group

three

patients

were

:

A. P., a femaIe, age twenty-nine, for three months had used the right thumb to press an emery cIoth against materia1 in a Iathe. Rather suddenIy a trigger thumb appeared. ExpIoration showed a thickening of the tendon with a constriction of the sheath at the same IeveI. RemovaI of the sweIIing on the tendon and Ieaving a window in the sheath reIieved a11 symptoms. Microscopic study of the noduIe showed scar tissue formation. One week of disabiIity foIIowed the operation In a11 probabiIity this condition was the resuIt of irritation of the tendon and sheath rom her occupation.

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L. H., a femaIe, age thirty-seven, complained of pain in the flexor surface of the right thumb foIIowing one month of work on an assembly line in which she constantIy used the thumb, screwing caps on smaI1 shells. Examination showed a definite trigger thumb. ExpIoration reveaIed a buIging of the tendon with a constriction of the sheath at the IeveI of the metacarpophaIangea1 joint. Part of the constriction of the sheath was excised, aIlowing free motion of the tendon. The patient was compIeteIy recovered fourteen days foIIowing the operation. C. S., a maIe, age fifty, puIIed trucks over uneven surfaces for six months. There appeared a graduaIIy increasing pain in the palm of the right hand, increasing to the point of complete disability. Examination reveaIed a tender noduIe in the paIm, on the Aexor tendon of the middIe finger. ExpIoration showed a noduIe on the tendon with adhesions to the sheath. The noduIe was removed and showed microscopicaIIy to be a low grade inff ammatory cicatrix. Postoperative disabiIity amounted to twenty-eight days. SUMMARY

In summarizing our seventy cases of tenosynovitis during a period of tweIve months, we find that sixty-two patients were treated by conservative methods and eight were operated upon. Of the sixty-two nonoperative cases, disabiIity ranged from none to sixty days, a tota of 933, or an average of fifteen days disabiIity per case. Of the eight patients operated upon, disabiIity before operation ranged from none to fifty-nine days, or a tota of I 19 days. The postoperative disabiIity in these cases totaIed 170 days, or twenty-one days per patient. WhiIe statistics prove IittIe or nothing, our coIIected figures suggest an improvement in our procedure. In a11 of our operative cases except one, expIoration was done on definite physica findings, nameIy, the presence of a noduIe on the tendon or the snapping or cIicking on motion. In one case (L. B.) conservative treatment was empIoyed for fifty-six days, and as IittIe improvement was obtained, the tendon

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was expIored, showing a narrowing of the sheath with adhesions. In reviewing our cases in which we used conservative treatment, we find fourteen cases with a disabiIity of more than twenty days, giving a totaI disabiIity of 542 days, an average of thirty-nine days per case. Therefore, with an average convaIescence of twenty-one days, even if we found nothing on expIoration, we wouId have added nothing to the period of disability. Again, on expIoring those cases which did not respond to conservative treatment within twenty days,

DECEMBER,,943

we might find some organic condition that couId not be determined on physica examination. From now on, we intend to expIore a11 cases of tenosynovitis that do within no-t show decided imprbvement twenty days. REFERENCES

I. MORITZ, ALAN R. The 2. 3 .

Pathology of Trauma. Philadelphia, 1942.Lea & Febiger. HOWARD, NELSON J. P&tendinitis crepitans. J. Bone CYJoint Surg., Vol. XIX 19: 447, 1937. PACK, GEORGET. Tumors of the Hand and Feet. St. Louis, 1939. C. V. Mosby Co.

THE prognosis of gas-bacillus infection depends upon the patient’s resistance, the part of the body involved, the virulence of the organism and the treatment. The extent of operative treatment depends upon the severity of the individua1 case.