Tendovaginitis

TENDOVAGINITIS (tendovaginitis), inflammation of the tendon sheaths, develops either as an independent disease or as a complication of some specific or infectious process. Inflammation of the tendon sheaths can be serous, serofibrinous, or purulent, and acute or chronic depending on the nature of the infection and course of the process. Depending on anatomical changes, crepitating T. (tendovaginitis crepitans) and stenosing T. (tendovaginitis stenosans de Quervain) are distinguished. Serous T. are mostly of specific nature (syphilis, tuberculosis) (see Tendon). Crepitating T. is a fairly common disease developing in the extremities, more often in manual laborers who have to perform rapid and uniform movements during work (Goldman). According to Blagovidov, Eisenstein, Rudenko, crepitating T. is often observed in molders, stocking knitters, brick molders, and workers in heavy metallurgy. This disease is characterized by the formation of a painful swelling along the course of the tendon sheath, mainly during movement, and the appearance of a special crackling sound when moving the extremity, clearly felt by both the patient and the examiner; for this, it is sufficient to place one's hand (fingers) on the painful swelling of the affected extremity and ask the patient to make several movements with the affected organ. The appearance of the crackling sound is explained differently by various authors. According to Billroth, the crackling occurs because the surfaces of the tendons and tendon sheaths become rough due to the deposition of fibrin (Volkmann compares it to dry pleurisy). Küttner reported at the 36th Congress of German Surgeons based on the work of Weiss and Seemann that in crepitating T. of the extremities, a fibrinous effusion appears between the muscle's own fascia and fascia cruris; König speaks of a serohemorrhagic effusion in the tendon sheath. In the literature, there are 3 cases of patho-anatomical examination in crepitating T.: in all three cases of crepitating T. at different times from the onset of the disease (14th and 5th day of illness), fibrinous deposits were not found. Only swelling of the loose connective tissue and a large number of blood vessels were noted, partly with rudiments of newly formed tissue in the parietendinous tissue. The tendon is glistening, unchanged. Crepitating T. most often localizes on the dorsal surface of the forearm: out of 234 cases, 66% of the disease was on the dorsal surface of the forearm, 17% on the anterior surface of the leg, 7% on the back of the hand, 5% on the Achilles tendon, etc. Sometimes isolated involvement of individual tendons can be noted, for example, of the extensor of the thumb. Then a painful swelling appears 4 cm above the styloid process of the radius (spina radii); with particularly strenuous work, there is pain when moving the thumb to grasp and hold an object. A crackling sound is clearly heard when moving the thumb, mainly when it is abducted. This crackling sound gave the disease its name tenalgia crepitans. Crepitating T. of the lower extremity occurs in people who make prolonged movements with the lower extremities in connection with their profession, for example during long marches in the army. Some authors believe that crepitating T. is a consequence of muscle strain, trauma to the peritendinous connective tissue - on the forearm by the type of kneading, and on the leg by the type of stretching; others believe that in its etiology, besides mechanical causes (strain), endogenous causes, rheumatism, also play a role. It should be noted that crepitating T. can develop independently of profession if prolonged work requires making movements unusual for the body. Therefore, crepitating T. most often develops in beginners and considering it a professional disease for any type of industry is not entirely correct. The disease develops more often in the right hand than in the left, which is explained by the predominant participation of the right hand in labor processes. Extensors are affected more often than flexors. Crepitating T. proceeds as an acute disease; in individual cases, crepitating T. can develop very quickly after trauma. The diagnosis of crepitating T. is not difficult. The presence of a painful swelling and a clearly expressed crepitation during movement (active or passive) and impairment of function of the affected organ are sufficiently characteristic signs of the disease; nevertheless, some authors (König) consider it necessary to warn about errors that occur, for example when crepitation was mistaken for the crackling in a fracture - especially in cases when crepitating T. developed quickly after trauma. Many methods have been proposed for the treatment of crepitating T. Most authors agree on providing rest to the affected extremity first. In addition, they recommend auxiliary measures in the form of compresses, ointments (mercurial, ichthyol), diathermy. König recommends tight bandaging and notes that strong pressure on the site of the painful swelling very quickly leads to a decrease in pain and rapid elimination of the process. Some authors (Goldman) recommend treatment by cauterization, creating a first-degree burn at the site of the disease. The method is based on deep heating of the extremity. At first, providing just one resting position for the extremity (relief from work, fixation of the extremity, splint bandage) is often sufficient for the pain to subside and the crackling and swelling to decrease. Subsequently, baths and gymnastics accelerate healing. The average duration of the disease ranges from 5 to 10 days. In individual cases, the disease can last more than 2 weeks and sometimes pass into a chronic form. The latter requires physical therapy methods and in a certain percentage of cases can lead to loss of working capacity. Stenosing T. (tendovaginitis stenosans) of the thumb was first described by de Quervain in 1895. The disease is characterized by the appearance of thickening in the area of the distal end of the radius, which corresponds to the thickening of the common tendon sheath of the short extensor of the thumb and the long abductor muscle. The disease develops gradually, with the appearance of thickening, pain on palpation and especially severe pain when moving the thumb also appear. There is no crepitation. The anatomical snuffbox area is smoothed out and somewhat swollen. In stenosing T., the tendon sheath significantly thickens, granulations grow in its wall, which begin to press on the tendon and cause pain. The tendon itself is unchanged, although the wall of the tendon sheath has clear signs of inflammation. Sometimes the tendon sheath thickens 2-3 times compared to normal, and its lumen sharply narrows. The disease proceeds chronically. In the pathogenesis of the disease, overexertion of the hand muscles is indicated. Regarding the treatment of stenosing T., it is recommended that in severe cases, an incision-opening of the tendon sheath and partial excision of its changed wall be performed. Purulent T. develop either after direct injuries to the tendon sheaths with their subsequent infection (splinters, puncture wounds) or after the spread of a purulent process from a neighboring focus to the tendon sheath, for example in paronychia. According to their localization, purulent T. most often develop on the hands (according to Klyucharev, purulent T. of the hands account for 43.4% of all purulent T.). For the clinical picture of purulent T., see Paronychia.