Tenosynovitis, a wrist condition which many people are unaware of.

1. Case study on tenosynovitis
J. Anisha Ebens
Pharm D intern

2. Tenosynuvitis:
• Tendons are strong bands of tissue that attach muscles to bone. In the thumb, they are
involved in moving the thumb.
• Tenosynovitis is the inflammation of the fluid-filled sheath (called the synovium) that
surrounds a tendon, typically leading to joint pain, swelling, and stiffness. Tenosynovitis
can be either infectious or noninfectious. Common clinical manifestations of
noninfectious tenosynovitis include de Quervain tendinopathy and stenosing
tenosynovitis (more commonly known as trigger finger)
• It’s a painful inflammation of tendons in your wrist and lower thumb. When the swollen
tendons rub against the narrow tunnel they pass through, it causes pain at the base of
your thumb and into the lower arm.

3. Causes:
• Infectious tenosynovitis occurs between 2.5% - 9.4% of all hand infections. Kanavel's
cardinal signs is used to diagnose infectious tenosynovitis. They are: tenderness to touch
along the flexor aspect of the finger, fusiform enlargement of the affected finger, the
finger being held in slight flexion at rest, and severe pain with passive extension. Fever
may also be present but is uncommon.
Doctors often don’t know why you get de Quervain's tenosynovitis. But it does result from:
• A direct blow to the thumb / Gaming
• Hobbies like gardening or racket sports
• Inflammatory conditions like rheumatoid arthritis
• Overuse or Repetitive workplace tasks
• Tenosynovitis and diabetes - Kameyama et al found evidence that among patients with
stenosing FT, those with diabetes have a higher prevalence of multiple joint involvement
than do those without diabetes.

4. Who Gets It?
Anyone can get de Quervain's tenosynovitis. But these things make it
more likely:
• Age: Adults between 30 and 50 are most likely to get it.
• Gender: Women are 8 to 10 times more likely to get it than men.
• Motherhood: It often happens just after pregnancy. Lifting your
little bundle of joy repeatedly might bring it on.
• Motions: You can get the condition if you move your wrist over
and over again, whether it’s for fun or for work.

5. Symptoms:
• Pain along the back of your thumb, directly over the two tendons.
• Swelling and pain at the base of your thumb
• Swelling and pain on the side of your wrist
• The condition can happen gradually or start suddenly. In either
case, the pain may travel into your thumb or up your forearm.
• It may be hard and painful to move your thumb, particularly
when you try to pinch or grasp things. The pain may get worse
when you move your thumb or wrist.

6. Diagnosis:
• The doctor will check your hand to see if it hurts when
he puts pressure on the thumb side of your wrist.
• Next, you’ll get the Finkelstein test. The doctor will ask
you to bend your thumb across your palm. Then you’ll
bend your fingers down over your thumb to make a fist.
This movement stretches your tendons. If it hurts on the
thumb side of your wrist, you probably have de
Quervain's tenosynovitis.
• Aspirated fluid can also be cultured to identify the
infectious organism. X-rays are typically unremarkable
but can help rule out a broken bone or a foreign body
• In some cases, your doctor may order an ultrasound or
MRI scan to confirm a diagnosis or rule out other
possible causes such as arthritis.

8. Treatment :
The treatment for tendon sheath inflammation focuses on reducing
inflammation and pain. One strategy is to rest the affected area and stop
the activities that caused the initial injury.
• Applying heat or cold may also help reduce swelling and pain.
• massage
• stretching the affected area
• medications for tendon sheath inflammation – NSAID’s
• Injection of the tendon sheath with a steroid is usually successful (in
noninfectious cases) and occasionally surgery is necessary to release the
tendon sheath about the tendon. If your condition was caused by an
infection, your doctor may prescribe antibiotics to fight the infection.

9. Exercises:

10. A female patient of age 40, was admitted in GM on 3.01.2019
C/O: Pain & swelling in Left arm
Itching all over the body.
H/O: Swelling since 5days.
No H/O trauma/ injury
O/E: Cellulitis Lt hand
Swelling, redness, tenderness +
Past Medical History:
K/C/O- DM x 2yrs on Rx

11. Past Medication History: T. Metformin 500mg BD
T. Janumet 50/500mg BD
Inj. Humalog 50/50 10-0-8 x 2yrs
Ortho opinion: Peri scaphoid swelling Lt +
Allergies: Yes- Dust
Surgical history: Nil
Personal History: Takes mixed diet.
Social Habits: Nil
Vitals: Normal, patients was conscious and oriented
General Examination:
Temp.: Afebrile BP: 110/70
PR : 80 beats/min RR: 20 breaths/min

12. Systems examination:
CVS: S₁S₂ + RS: NVBS +
CNS: NFND P/A: soft
Lab investigation:
Parameters Report values Normal values
HB 12.8 12 – 16 g/dl
TLC 8600 3800 – 11000 Cells/mm³
DC N-61, L-33, E-6 N: 45-75, L: 16-46, E: 0-8
BT/CT 1’50”/4’10” 2-7/8-15 mins
BUN 22 8 – 25mg/dl
Cr 0.5 0.5 – 1.1 mg/dl
FBS 170 70 – 110 mg/dl
PPBS 367 <140 mg/dl
HbA1C 8.7% 4 – 5.5%
T. Chol 109 <200mg/dL

13. Other investigation:
X-Ray, Venous Doppler Lt or Arterial Upper Limb
Impression: X-ray – PeriScaphoid Swelling
Venous Doppler – No thrombosis seen in upper limb
veins, subcutaneous edema – possibility of extensor digitorum
tenosynovitis.
Diagnosis: Tenosynovitis

14. Drug Chart:
S.No Drug name Dose ROA Freq. No. of days
1 Inj. Ertapenum 1 g IV 1-0-1 3-9
2 Inj. Metronidazole 400mg IV TDS 3-9
3 Inj. Colymonas 2 million U IV BD 3-9
4 Inj. Ranitidine 50mg IV BD 3-5
5 Inj. Diclofenac 100mg IM BD 3-9, tab -10,11
6 T. Spade 1 tab P/O BD 3-11
7 T. MVT 1tab P/O BD 3-9
8 T. MF 500mg P/O TDS 3-11
9 T. Sitagliptin 50mg P/O OD 3-11
10 Inj. Novomix 30/70 SC 12-0-10 3-11
11 Inj. Heparin 2500 IU SC BD 4-8
12 Inj. Pantoprazole 2cc (40mg) IV BD 6-11
13 T. Linezolid 600mg P/O BD 10, 11
14 T. Menoctyl 10mg P/O BD 10, 11
15 T. Prednisolone 10mg P/O 1-0-1 10, 11

15. Discarge advice:
Patient discharged on 11.1.19 with the following drugs
T. Rantac 150mg BD
T. Spade 1 tab BD
T. MVT 1tab OD
T. Prednisolone 10mg BD
T. Linezolid 600mg BD
T. Menoctyle 10mg BD and OHD’s
The patient was asked to review after 1 week.

16. FARM Notes:
Findings: Major interaction: Diclofenac & Prednisolone
Assesment: Diclofenac & Prednisolone – concurrent use increase toxicity
by synergistic effect.
Resolution: Diclofenac or Prednisolone can be used.
Monitoring: Check for bleeding. Monitor closely.
Pharmacist Intervention:
Diagnosis would have been done as early as possible.
Heparin is given without any indication.
Glucose monitoring is not done on regular basis.
Culture test should have been done.