• Tendovaginitis - Causes, symptoms and treatment. MF.

    Tendovaginitis is an inflammation of the inner lining of the fibrous vagina of the muscle tendon, that is, the synovial membrane. The synovial membrane facilitates the sliding of the corresponding tendon in the osteo-fibrous canals when performing muscular work.

    Figure 1. Schematic representation of tenosynovitis - inflammation of the synovial membrane of the fibrous vagina of the muscle tendon.

    Distinguish between acute and chronic tenosynovitis.
    Acute tenosynovitis of is manifested by edema of the synovium and accumulation of fluid in the cavity of the synovial membrane.
    Chronic tendovaginitis is accompanied by thickening of the synovium and accumulation in the synovial cavity of the effusion with a high content of fibrin. Over time, as a result of the organization of fibrinous effusion, the so-called "rice bodies" are formed, and the lumen of the tendon sheath decreases.
    Depending on the nature of the inflammatory process, there are serous, serous-fibrinous, and purulent tenosynovitis.

    Causes of tendovaginitis

    Depending on the causes of the onset, the following groups of tendovaginitis can be identified:

    1) independent aseptic tendovaginitis, the occurrence of which is a consequence of prolonged microtraumatism and overstrain of synovial vaginas of tendons and adjacent tissues in persons of certain occupations( joiners, locksmiths, loaders,typists, pianists, stockists, masonry brickworkers, workers in the heavy metallurgical industry) who perform long-termThere are similar movements in which a limited group of muscles participates;In addition, such tendovaginitis can appear in athletes( skiers, skaters and others) in overtraining.
    2) infectious tendovaginitis:
    a) specific tendovaginitis in some infectious diseases( such as gonorrhea, brucellosis, tuberculosis, etc.), in which the spread of pathogens is more often hematogenous( with blood flow);B) non-specific tenosynovitis in purulent processes( purulent arthritis, panaritium, osteomyelitis), from which the inflammation spreads directly to the synovial vagina, as well as with injuries;
    3) reactive tendovaginitis, the appearance of which accompanies rheumatic diseases( rheumatism, Bekhterev's disease, rheumatoid arthritis, systemic scleroderma, Reiter's syndrome and others).

    Symptoms of tendovaginitis

    For acute non-specific tendovaginitis is characterized by an acute onset and rapid development of painful swelling in the location of the affected synovial sheaths of the tendon sheaths. Most often, acute tendovaginitis occurs in the tendon sheaths on the back surface of the feet and brushes, more rarely in the synovial vagina of the fingers and in the vagina of the flexor tendons of the fingers. Edema and tenderness, as a rule, spread from the foot to the shin and from the hand to the forearm. There is a restriction of movement, it is possible to develop flexion contracture of the fingers. If the inflammatory process becomes purulent, body temperature rises quickly, chills appear, regional lymphadenitis develops( lymph nodes increase due to inflammation) and lymphangitis( inflammation of the lymphatic vessels).Purulent tendovaginitis more often develops in the area of ​​the vagina of tendons of flexor flexors.

    For acute asseptic tendonitis of is characterized by the defeat of synovial vaginas on the back surface of the hand, not so often - the feet, even less often - the intercampis synovial vagina of the biceps( biceps muscles of the shoulder).The onset of the disease is acute: a swelling is formed in the area of ​​the affected tendon, when probed, there is a crepitation( crunching).There is a restriction of the movement of the finger or tenderness when moving. A transition to a chronic form of the disease is possible.

    For chronic tendovaginitis is characterized by the defeat of the vagina of flexor tendons and extensor fingers in the area of ​​their retainers. Often there are symptoms of chronic tendovaginitis of the common synovial vagina of the flexor of the fingers - the so-called carpal tunnel syndrome, in which a tumor-shaped, painful elongated shape is formed in the region of the wrist canal, having an elastic consistency and often taking the shape of an hourglass that moves slightly during movement. Sometimes you can feel the "rice bodies" or determine the fluctuation( sensation of the transfer wave, caused by the accumulation of fluid).Characteristic limitation of tendon movements.

    Especially distinguish the peculiar form of chronic tenosynovitis - the so-called stenosing tendovaginitis, or the tendonitis of de Kervena , which is characterized by the defeat of the vagina of the tendon of the short extensor and the long excretory muscle of the thumb of the hand. The walls of the vagina with this form of tendovaginitis thicken, and the cavity of the synovial vagina, respectively, tapers. Tendovaginitis de Kervena is manifested by pains in the location of the styloid process of the radius, which often radiate to the first finger of the hand or to the elbow, as well as swelling. The pain intensifies if the patient presses the finger to the palmar surface and bends the rest of the fingers over it;if at the same time the patient takes the wrist to the elbow, the pain is abrupt. In the course of the vagina palpation, an extremely painful swelling is determined.

    The tubercular tendovaginitis is characterized by the formation of dense formations( "rice bodies") along the extensions of the tendon sheaths, which can be palpated( palpated).

    Complications of tendovaginitis

    Purulent radial tenobursitis - is, as a rule, a complication of purulent tenosynovitis of the thumb of the hand. It develops if the purulent inflammation spreads to the entire vagina of the tendon of the long flexor of the thumb of the hand. Characterized by severe soreness along the palmar surface of the thumb of the hand and further along the outer edge of the hand to the forearm. If the disease progresses, the purulent process can spread on the forearm. Purulent ulnar tenobursitis - is, as a rule, a complication of purulent tendovaginitis of the little finger of the hand. Because of the peculiarities of the anatomical structure, the inflammatory process quite often passes from the synovial vagina of the little finger to the common synovial vagina of the flexor of the hand, at least to the synovial vagina of the tendon of the long flexor of the thumb. In this case, the so-called cross phlegmon develops, which is characterized by a severe course and is often complicated by a disruption in the functioning of the hand. Characterized by severe soreness and swelling of the palmar surface of the hand, thumb and little finger, as well as a significant restriction of extension of the fingers or its complete inability.

    Carpal tunnel syndrome: its appearance and clinical manifestations are caused by compression in the carpal tunnel of the median nerve. Characterized by sharp pain and a sense of numbness, tingling sensation, crawling crawling in the area( paresthesia) of the first, second, third fingers of the hand, and also the inner surface of the fourth finger. There is a decrease in the muscle strength of the hand, the sensitivity of the tips of these fingers is reduced. Pain intensification occurs at night, which leads to sleep disturbance. There may be some relief when the hand is lowered and waved. Quite often there is a discoloration of the skin of the painful fingers( blueness of the tips, pallor).Perhaps a local increase in sweating, a decrease in pain sensitivity. When you feel your wrist, swelling and soreness are determined. The forced flexion of the hand and the raising of the hand upwards can cause the aggravation of the pain syndrome and paresthesias in the area of ​​innervation of the median nerve. Often, carpal tunnel syndrome is combined with the Guyon channel syndrome, which is very rare. With the syndrome of the Huyon canal, as a result of the ulnar nerve being compressed in the region of the pea, pain and numbness, tingling sensations, crawling in the IV, V fingers, swelling in the area of ​​the pea and pain when palpable.

    Inspection and laboratory diagnostics of tenosynovitis

    Diagnosis of tendovaginitis allows the characteristic localization of the pathological process and the data obtained during clinical investigation( cord-like form of painful compaction in typical places, impaired movement, determination of "rice bodies" during palpation).

    In a laboratory examination in acute purulent tenosynovitis, a leukocytosis is determined in the general blood test( UAC)( increase of white blood cells over 9 x 109 / L) with an increase in the content of stab neutrophil forms( above 5%), an increase in ESR( erythrocyte sedimentation rate).Pus is examined by bacterioscopy( examination under a microscope after a special coloring of the material) and bacteriological( isolation of pure culture on nutrient media) by methods that enable to establish the nature of the pathogen and determine its sensitivity to antibiotics. In cases where the course of acute purulent tendovaginitis is complicated by sepsis( when the pathogen is spread from the purulent focus to the blood stream), the blood is tested for sterility, which also allows to determine the nature of the pathogen and determine its sensitivity to antibacterial drugs.

    When X-ray examination is characterized by the absence of pathological changes from the joints and bones, only the thickening of soft tissues in the corresponding area can be determined.

    Differential diagnosis of

    Chronic tenosynovitis should be differentiated with Dupuytren's contracture( painless progressive flexion contracture of the IV and V fingers of the hand), acute infectious tendovaginitis - with acute arthritis and osteomyelitis.

    Treatment of tendovaginitis

    Treatment of acute tenosynovitis is divided into general and local.
    General treatment for nonspecific acute infectious tendovaginitis provides for the fight against infection, for which use pritovobakterialnye funds, as well as measures to strengthen the body's defenses. With tuberculosis tenosynovitis , anti-tuberculosis drugs( streptomycin, ftivazid, PASK and others) are used. The general treatment of with aseptic tendovaginitis involves the use of non-steroidal anti-inflammatory drugs( aspirin, indomethacin, butadione).

    Local treatment of in both infectious and aseptic tendovaginitis in the initial stage is reduced to ensuring resting of the affected limb( in the acute period of tenosynovitis is immobilized with gypsum longtose), using warming compresses. After it is possible to achieve the abatement of acute phenomena, physiotherapeutic procedures( ultrasound, UHF, microwave therapy, ultraviolet rays, hydrocortisone and novocaine electrophoresis), therapeutic exercise are used. With a purulent tendovaginitis, the vagina of the tendon and the purulent swelling are urgently opened and drained. In the case of tubercular tenosynovitis , local injection of streptomycin solution and excision of affected synovial vaginas are performed.

    In , the treatment of chronic tendovaginitis uses the above methods of physiotherapy, and also appoints paraffin or ozocerite applications, massage and electrophoresis of lidase;classes of physiotherapy exercises. If the chronic infectious process progresses, punctures of the synovial vagina and administration of antibiotics of directed action are shown. With chronic aseptic tendovaginitis non-steroidal anti-inflammatory drugs are used, local administration of glucocorticosteroids( hydrocortisone, methipred, dexazone) is effective. In the case of poorly treatable chronic crepitic tendovaginitis sometimes resort to X-ray therapy. In some cases, with the ineffectiveness of conservative therapy of stenosing tendovaginitis, surgical treatment is performed( dissection of narrowed channels).

    Tendovaginitis, accompanying rheumatic diseases , are treated the same way as the main disease: prescribe anti-inflammatory and basic drugs, electrophoresis of nonsteroidal anti-inflammatory drugs, hydrocortisone phonophoresis.

    Prognosis for tenosynovitis

    In case of timely initiated and adequate treatment, tendovaginitis is characterized by a favorable prognosis. However, with purulent tendovaginitis, persistent violations of the function of the affected hand or foot can sometimes remain.

    Doctor surgeon Kletkin ME