Dorsal Tenosynovitis

Description

• In patients with dorsal tenosynovitis, the tenosynovium becomes hypertrophic and causes pain as the extensor tendons move on the dorsum of the hand and wrist.
• Persistent proliferative dorsal tenosynovitis can cause extensor tendon rupture.¹
• If the tenosynovitis affects only the first dorsal compartment, which includes the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB), it is called de Quervain’s disease. Symptoms of de Quervain’s include swelling at the radial styloid. However, de Quervain’s often occurs with hypertrophic tenosynovial changes.²

Pathophysiology

• Dorsal tenosynovitis may arise from rheumatoid arthritis (RA), osteoarthritis or tuberculosis. Patients presenting with RA often have involvement of the radiocarpal and distal radioulnar joints and the overlying extensor tendons.¹

Instructions

1. Palpate along the extensor tendons in the affected wrist to check for tenderness, nodules, crepitus and visible dorsal swelling caused by the hypertrophic tenosynovium³
2. Check for associated intra-articular synovitis of the radiocarpal or radioulnar joints

Variations

• It is important to evaluate the patient’s contralateral wrist as a comparison, because this test may be painful even in a healthy wrist.¹

Diagnostic Performance Characteristics

• If dorsal tenosynovitis cannot be diagnosed by physical tests alone, then tendinopathy may be seen on ultrasound or MRI with fluid-sensitive sequences in the axial plane.
• Tenosynovitis will represent itself as fluid in the sheath.³

• A positive result occurs when the exam demonstrates hypertrophic tenosynovitis attached to the extensor tendons, which can produce pain, especially as the patient attempts to extend the fingers and the thickened tenosynovial tissues collide with the dorsal wrist extensor retinaculum. 

• A negative result occurs when the patient’s exam does not demonstrate hypertrophic tenosynovial changes along the course of the extensor tendons.

• When a patient with RA presents with recurrent dorsal tenosynovitis, an expanding tenosynovial tissue mass and dorsal dislocation of the ulnar head, surgery may be required.¹
• Rupture of the wrist extensor tendons can be related to severe joint disease, severe hypertrophic tenosynovium or RA nodules in the extensor tendons.¹

1. Richards RA, Wilson RL. Management of Extensor Tendons and the Distal Radioulnar Joint in Rheumatoid Arthritis. J Hand Surg Am 2003;3(3):132-44.
2. Sauvé P, Rhee P, Shin A, Lindau T. Examination of the Wrist: Radial-Sided Wrist Pain. J Hand Surg Am 2014;39(10):2089-92. PMID: 25200760
3. Culp R, Jacoby S. Musculoskeletal Examination of the Elbow, Wrist and Hand: Making the Complex Simple. New Jersey: SLACK Incorporated, 2012.