Tenosynovitis

KEY FACTS

Imaging

• Occurs only in tendons encased by synovium
• Distension of tenosynovium (tendon sheath) due to fluid or synovitis with variable tendon swelling
• Acute exudative tenosynovitis

Usually due to acute infection or gout

Fluid accumulation within sheath with little or no synovial proliferation

Fluid may have speckled echogenic appearance due to aggregates of debris or pus
• Acute nonexudative tenosynovitis

Usually due to infection, inflammatory disease, or gout

Synovial proliferation within sheath predominates over fluid accumulation
• Chronic tenosynovitis (active)

Synovial proliferation within hyperemia with tendon sheath
• Chronic tenosynovitis (inactive)

Clear fluid accumulation within mildly thickened sheath

Hyperemia mostly around, rather than within, tendon sheath
• Stenosing tenosynovitis

Hypertrophy of retinaculum or pulley component of tendon osseofibrous tunnel

Restricts tendon movement (trigger finger and de Quervain disease)

Diagnostic Checklist

• Tenosynovitis: Disease of tendon sheath with minimal tendon involvement
• Tendinosis: Disease of tendon with variable degree of peritendinitis
• Use color Doppler to distinguish synovial inflammation from synovial effusion
• Use minimal transducer pressure to avoid effacing tendon sheath effusion or vascularity

TERMINOLOGY

Synonyms

• Tendinitis or tendonitis are arbitrary terms best avoided

IMAGING

General Features

• Best diagnostic clue

Inflammation of tendon sheath (tenosynovium)

Thickening of synovial tendon sheath (synovial proliferation)

Exudate or fluid within tendon sheath form “halo” around tendon
• Location

Can occur only in tendons encased by synovial sheath

Wrist extensors > wrist flexors > finger flexors > ankle tendons

– Tenosynovitis cannot occur if no tendon sheath present

For example, flexor carpi ulnaris tendon has no tendon sheath

Extensor digitorum tendons of fingers have no tendon sheath
• Morphology

Distension of tendon sheath with mild tendon swelling

Variable tendon sheath distension and content, depending on cause, severity, duration

Radiographic Findings

• Radiography

Signs of underlying cause

– Calcifications in gouty tophi or calcium pyrophosphate dihydrate deposition

– Erosive or septic arthropathy

– Radiopaque foreign body

MR Findings

• T2WI

Fluid signal within distended synovial sheath
• T1WI C+ FS

Contrast enhancement helps differentiate synovial proliferation from tendon sheath fluid

Ultrasonographic Findings

• Depends on capacity of tendon sheath to distend
• Acute exudative tenosynovitis

Usually due to infection and gout

– Fluid accumulation within tendon sheath with little or no synovial proliferation

Forms hypoechoic halo around tendon

– Fluid may have speckled echogenic appearance due to aggregates of debris or pus

Echogenic comet-tail artifacts due to gouty crystal aggregates tend to be larger than those due to inflammatory aggregates in infected tenosynovial fluid

– Hyperemia around but not within tendon sheath

– Infection may spread from tendon sheath into peritendinous tissues

– ± foreign body within tendon sheath
• Acute proliferative tenosynovitis

Due to rheumatological disease, gout, or infection

– Distension of tendon sheath with minimal or no tendon swelling

– Synovial proliferation within sheath predominates over fluid accumulation

– Hyperemia predominantly around rather than within tendon sheath

Mild secondary tendon sheath swelling can occur with severe cellulitis or edema in absence of actual tenosynovitis
• Chronic active tenosynovitis

Due to rheumatological disease, gout, or infection

Markedly thickened tendon sheath due to synovial proliferation rather than fluid

– Synovial proliferation particularly prevalent in tuberculous tenosynovitis

– Probe pressure can differentiate fluid from tenosynovial thickening

Fluid can be squeezed away but tenosynovial thickening is not fully compressible

Intrasheath hyperemia confirms tenosynovial proliferation rather than fluid

Established hyperemia both within and around tendon sheath

± tendon rupture

– Chronic inflammation weakens tendon
• Chronic inactive tenosynovitis

Either synovial proliferation or clear fluid accumulation within mildly thickened sheath

– Multiple “rice bodies” (small fibrinous nodules) may develop in chronic inflammation (e.g., tuberculosis or rheumatoid arthritis)

– Adhesions can lead to entrapped tenosynovial fluid with marked distension

Little or no hyperemia either around or within tendon sheath
• Stenosing tenosynovitis

Describes tendon disorders associated with hypertrophy of fibrous component of tendinous osseofibrous tunnel

“Tenosynovitis” terminology is contentious as this entity is more related to tendinosis than tenosynovitis

Hypertrophy of flexor pulley (trigger finger) or 1st extensor retinaculum (de Quervain disease)

– For trigger finger, A1 pulley is thickened more frequently than A2 pulley, and any finger may be affected

Thickening (1-1.5 mm) of pulley or retinaculum

– Normal thickness of pulley or retinaculum ≤ 0.5 mm

± hyperemia of retinaculum or tendon thickening

Occasional tendon sheath effusion

Restriction of tendon movement on dynamic imaging

Imaging Recommendations

• Best imaging tool

US: Accurate at revealing presence and extent of tenosynovitis

– Facilitates fine-needle aspiration (for culture, crystals) or biopsy to determine cause

– US-guided steroid injection treatment

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Apr 9, 2020 | Posted by admin in MUSCULOSKELETAL IMAGING | Comments Off

KEY FACTS

Imaging

TERMINOLOGY

Synonyms

IMAGING

General Features

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Tenosynovitis

Tenosynovitis

Diagnostic Checklist

Radiographic Findings

MR Findings

Ultrasonographic Findings

Imaging Recommendations

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Tenosynovitis

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