FLEXOR TENOSYNOVITIS OF THE WRIST: A COMPREHENSIVE REVIEW OF CURRENT KNOWLEDGE
DOI:
https://doi.org/10.31435/ijitss.3(51).2026.6249Keywords:
Tenosynovitis, Wrist, Tendons, Carpal Tunnel Syndrome, Rheumatoid ArthritisAbstract
Introduction and purpose. Flexor tenosynovitis of the wrist is inflammation of the volar (palmar) flexor tendon sheaths, an under-recognized but clinically important cause of volar wrist pain, swelling, and median-nerve symptoms. It spans mechanical, calcific, inflammatory, and infective forms that mimic one another and delay correct treatment. This review consolidates current knowledge on its anatomy, etiology, diagnosis, and management.
Materials and methods. This review synthesized 55 articles, spanning 1940 to 2026, identified through an extensive search of PubMed and limited to English-language publications; no date restriction was applied, so that landmark anatomical descriptions could be retained alongside contemporary practice. Data were synthesized descriptively, organized by pathophysiology, clinical presentation, diagnosis, and management.
Description of the state of knowledge. The condition comprises mechanical (notably flexor carpi radialis), calcific, inflammatory (rheumatoid), and infective (pyogenic, tuberculous, nontuberculous mycobacterial, and fungal) forms that overlap clinically and may compress the median nerve, causing secondary carpal tunnel syndrome. Diagnosis combines clinical examination with radiographs, ultrasound, and magnetic resonance imaging, supplemented by histopathology or culture when the cause is unclear. Management is form-specific, ranging from immobilization and anti-inflammatory drugs for self-limiting calcific disease, through corticosteroid injection, to tenosynovectomy with carpal tunnel release and urgent debridement for pyogenic infection, in which delay worsens outcomes.
Conclusions. Flexor tenosynovitis of the wrist is uncommon, etiologically diverse, and frequently misdiagnosed; early differentiation of its forms is the key to correct treatment. The evidence base rests largely on case reports and retrospective series rather than controlled trials.
References
Mohana-Borges, Á. V. R., Cheng, K., Moreno, M., & Chung, C. B. (2026). Tendon sheath, bursae, and clinically relevant peritendinous structures of the hand and wrist. Magnetic Resonance Imaging Clinics of North America, 34(1), 103–116. https://doi.org/10.1016/j.mric.2025.08.006
Shim, M. R. (2018). Unusual etiology of acute wrist pain: Acute calcific tendonitis of the flexor carpi ulnaris mimicking an infection. Case Reports in Orthopedics, 2018, 2520548. https://doi.org/10.1155/2018/2520548
Spratt, J. D., Mehl, A., & Lourie, G. M. (2024). Flexor carpi radialis tendinitis: A case series and algorithm. Journal of Hand Surgery Global Online, 6(4), 534–539. https://doi.org/10.1016/j.jhsg.2024.04.003
Parsaoran Butarbutar, J. C., & Suginawan, E. T. (2022). Calcified tendinitis of the flexor carpi ulnaris tendon: A case report. Journal of Orthopaedic Case Reports, 12(7), 10–13. https://doi.org/10.13107/jocr.2022.v12.i07.2894
Kumar, R., Lakkireddy, M., Maley, D., Eppakayala, S., Sathu, S., & Kashyap, A. (2023). Flexor tenosynovitis of the wrist with carpal tunnel syndrome. International Journal of Mycobacteriology, 12(1), 100–102. https://doi.org/10.4103/ijmy.ijmy_201_22
Sharma, P., Kale, A., & Jadhav, D. (2026). Secondary carpal tunnel syndrome due to flexor tenosynovitis in a diabetic patient. Annals of African Medicine. https://doi.org/10.4103/aam.aam_796_25
Pathak, P. K., Sinha, P. R., Agrawal, P., Gupta, N., & Jain, S. (2025). Isolated flexor tenosynovitis as the sole manifestation of rheumatoid arthritis: A case report. Journal of Orthopaedic Case Reports, 15(7), 211–215. https://doi.org/10.13107/jocr.2025.v15.i07.5828
Tiwari, P., Kaur, H., Bansal, N., & Jaura, S. S. (2022). Rheumatoid or tubercular: Flexor tenosynovitis of the wrist with rice bodies. Journal of Family Medicine and Primary Care, 11(10), 6518–6522. https://doi.org/10.4103/jfmpc.jfmpc_786_22
Lipatov, K., Asatryan, A., Melkonyan, G., Kazantcev, A. D., Solov’eva, E., Gorbacheva, I., Vorotyntsev, A. S., & Emelyanov, A. Y. (2026). Pyogenic flexor tenosynovitis: A current problem of hand surgery. Chinese Journal of Traumatology = Zhonghua Chuang Shang Za Zhi, 29(1), 40–46. https://doi.org/10.1016/j.cjtee.2024.10.008
Anderson, G. M., Proal, J. D., Crowe, C. S., & Kennedy, S. A. (2026). Management of pyogenic flexor tenosynovitis. JBJS Reviews, 14(4). https://doi.org/10.2106/JBJS.RVW.26.00015
Edis, P., Ozdemir, N., & Hekimsoy, Z. (2024). The musculoskeletal disorders in diabetic patients and the evaluation of their relationship with metabolic parameters and microvascular complications. Acta Endocrinologica (Bucharest, Romania : 2005), 20(2), 136–142. https://doi.org/10.4183/aeb.2024.136
Kwiecien, G. J., Logli, A. L., Brault, J., & Rizzo, M. (2023). Calcific tendinitis of the proximal flexor carpi radialis in a throwing athlete. Journal of Hand Surgery Global Online, 5(1), 69–72. https://doi.org/10.1016/j.jhsg.2022.10.011
Salsbury, C. R. (1940). A contribution to the anatomy of the ulnar bursa. Canadian Medical Association Journal, 43(5), 430–432.
Aguiar, R. O. C., Gasparetto, E. L., Escuissato, D. L., Marchiori, E., Trudell, D. J., Haghighi, P., & Resnick, D. (2006). Radial and ulnar bursae of the wrist: Cadaveric investigation of regional anatomy with ultrasonographic-guided tenography and MR imaging. Skeletal Radiology, 35(11), 828–832.
Fussey, J. M., Chin, K. F., Gogi, N., Gella, S., & Deshmukh, S. C. (2009). An anatomic study of flexor tendon sheaths: A cadaveric study. The Journal of Hand Surgery, European Volume, 34(6), 762–765. https://doi.org/10.1177/1753193409344529
Sharma, K. S., Rao, K., & Hobson, M. I. (2013). Space of parona infections: Experience in management and outcomes in a regional hand centre. Journal of Plastic, Reconstructive & Aesthetic Surgery : JPRAS, 66(7), 968–972. https://doi.org/10.1016/j.bjps.2013.03.020
Spratt, J. D., Mehl, A., & Lourie, G. M. (2025). Flexor carpi radialis tendinitis to rupture: A case series and algorithm. Journal of Hand Surgery Global Online, 7(6), 100859. https://doi.org/10.1016/j.jhsg.2025.100859
Urry, K. C., Sant, K. N., & Casaletto, J. A. (2024). Calcific tendinosis of flexor carpi radialis as a cause of wrist pain. Journal of Surgical Case Reports, 2024(12), rjae751. https://doi.org/10.1093/jscr/rjae751
Ahuja, A., Lawande, M., & Daftary, A. R. (2021). Role of radiographs and ultrasound in diagnosing calcific tendinitis and periarthritis in the wrist and hand with ultrasound-guided barbotage as management tool. The Indian Journal of Radiology & Imaging, 31(3), 605–610. https://doi.org/10.1055/s-0041-1736397
Patel, J., Tai, R., Sereni, C., & Joshi, G. (2024). Hydroxyapatite deposition disease, an overlooked differential diagnosis in the emergency department: A case series and review of literature. Emergency Radiology, 31(2), 229–238. https://doi.org/10.1007/s10140-024-02212-6
Gerster, J. C., & Lagier, R. (1989). Upper limb pyrophosphate tenosynovitis outside the carpal tunnel. Annals of the Rheumatic Diseases, 48(8), 689–691. https://doi.org/10.1136/ard.48.8.689
Chary-Valckenaere, I., Kessler, M., Mainard, D., Schertz, L., Chanliau, J., Champigneulle, J., Pourel, J., Gaucher, A., & Netter, P. (1998). Amyloid and non-amyloid carpal tunnel syndrome in patients receiving chronic renal dialysis. Journal of Rheumatology, 25(5), 972–978.
Malisetyan, T., Harmon, S. R., Reyes, M., Shoja, M. M., & Schwartz, G. (2024). Nontuberculous mycobacterial flexor tenosynovitis of the wrist and hand. Cureus, 16(4), e58716. https://doi.org/10.7759/cureus.58716
Kataria, S., Gangwar, S., Marupaka, S. K., & Ingle, A. (2025). Tuberculous chronic palmar bursitis and flexor tenosynovitis of the wrist: A case report. Cureus, 17(4), e82652. https://doi.org/10.7759/cureus.82652
Wang, S., Ro, H., Xu, H., Fang, L., & Li, X. (2026). Post-traumatic candida infection leading to bilateral wrist rice body tenosynovitis: A case report and literature review. Archives of Orthopaedic and Trauma Surgery, 146(1). https://doi.org/10.1007/s00402-026-06288-2
Agrawal, N., Jain, V., Agrawal, H., Upadhyay, A. K., & Rajavat, A. S. (2026). Tubercular compound palmar ganglion presenting with chronic wrist swelling and flexor dysfunction: A case report. Journal of Orthopaedic Case Reports, 16(5), 267–272. https://doi.org/10.13107/jocr.2026.v16.i05.7278
Hussain, S., Irfan, M., Khan, M., Khan, M. K., Awan, S. K., Raza, S. S., Adil, A. N. K., & Varrassi, G. (2025). From glycemia to grip: A comprehensive review of musculoskeletal complications in diabetic patients. Cureus, 17(8), e90838. https://doi.org/10.7759/cureus.90838
Hulshof, C. T. J., Colosio, C., Daams, J. G., Ivanov, I. D., Prakash, K. C., Kuijer, P. P. F. M., Leppink, N., Mandic-Rajcevic, S., Masci, F., Molen, H. F. van der, Neupane, S., Nygård, C.-H., Oakman, J., Pega, F., Proper, K., Prüss-Üstün, A. M., Ujita, Y., & Frings-Dresen, M. H. W. (2019). WHO/ILO work-related burden of disease and injury: Protocol for systematic reviews of exposure to occupational ergonomic risk factors and of the effect of exposure to occupational ergonomic risk factors on osteoarthritis of hip or knee and selected other musculoskeletal diseases. Environment International, 125, 554–566. https://doi.org/10.1016/j.envint.2018.09.053
Hennessy, M., Forder, B. H., Tucker, S., & Wormald, J. C. R. (2026). Optimal management of pyogenic flexor tenosynovitis of the hand: A cohort study. Journal of Hand and Microsurgery, 18(4), 100475. https://doi.org/10.1016/j.jham.2026.100475
Canarelli, E., Berry, C., Van Vliet, A., David, E., & Léon, M. (2025). Risk factors of flexor tendon tenosynovitis after distal radius fractures treated with volar locking plates: A case-control study. Orthopaedics & Traumatology, Surgery & Research : OTSR, 104347. https://doi.org/10.1016/j.otsr.2025.104347
Wick, M. C., Weiss, R. J., Arora, R., Gabl, M., Gruber, J., Jaschke, W., & Klauser, A. S. (2011). Enthesiopathy of the flexor carpi ulnaris at the pisiform: Findings of high-frequency sonography. European Journal of Radiology, 77(2), 240–244. https://doi.org/10.1016/j.ejrad.2009.12.019
Lee, H. I., Lee, K. W., Park, D., & Park, M. J. (2018). Pisiform excision for refractory flexor carpi ulnaris tendinopathy of the wrist. Acta Orthopaedica Belgica, 84(4), 539–545.
Fatou, C. N., Amadou, B. A., Badara, G. A., Badara, D., Mohamedi, D., & Bertini, D. C. (2017). Tuberculous tenosynovitis of the wrist and the hand: The 3 anatomo- clinical forms described by kanavel (about 4 cases). Journal of Orthopaedic Case Reports, 7(6), 68–72. https://doi.org/10.13107/jocr.2250-0685.954
Kim, D. H., Park, J. Y., Won, H.-C., & Park, J. S. (2023). Nontuberculous mycobacterial tenosynovitis of the hand: A 10-year experience at two centers in south korea. Clinics in Orthopedic Surgery, 15(3), 477–487. https://doi.org/10.4055/cios22248
Mamane, W., Lippmann, S., Israel, D., Ramdhian-Wihlm, R., Temam, M., Mas, V., Pierrart, J., & Masmejean, E. H. (2018). Infectious flexor hand tenosynovitis: State of knowledge. A study of 120 cases. Journal of Orthopaedics, 15(2), 701–706. https://doi.org/10.1016/j.jor.2018.05.030
Chapman, T., & Ilyas, A. M. (2019). Pyogenic flexor tenosynovitis: Evaluation and treatment strategies. Journal of Hand and Microsurgery, 11(3), 121–126. https://doi.org/10.1055/s-0039-1700370
Mehta, P., Thoppil, J., Koyfman, A., & Long, B. (2024). High risk and low prevalence diseases: Flexor tenosynovitis. The American Journal of Emergency Medicine, 77, 132–138. https://doi.org/10.1016/j.ajem.2023.12.023
Forder, B. H., Hennessy, M., Turner, B., & Wormald, J. (2024). Systematic review of treatment for pyogenic flexor tenosynovitis of the hand. Journal of Plastic, Reconstructive & Aesthetic Surgery : JPRAS, 96, 23–32. https://doi.org/10.1016/j.bjps.2024.05.039
Fujihara, Y., Sakai, A., Niwa, S., Ota, H., & Kumagai, H. (2024). Delayed debridement affects prognosis in patients with purulent flexor tenosynovitis: A retrospective cohort and multivariate analyses. Archives of Orthopaedic and Trauma Surgery, 144(5), 2437–2441. https://doi.org/10.1007/s00402-024-05269-7
Frizzell, K., Galvis, E., & Bhandari, L. (2022). A comparison of parenteral and per-oral antibiotic usage in pyogenic flexor tenosynovitis: A retrospective study. Cureus, 14(12), e32825. https://doi.org/10.7759/cureus.32825
Kelley, N., Holy, T., Wells, L., Imada, A., & Morrell, N. T. (2025). Comparison of outcomes in surgical treatment of pyogenic flexor tenosynovitis: Hand surgeons versus other orthopedic subspecialists. Orthopedics, 48(4), e162–e168. https://doi.org/10.3928/01477447-20250513-01
Lundén, K., Perez, R., Zimmerman, M., Merlo, J., & Dahlin, L. B. (2026). Socioeconomic inequalities of the hand infections pyogenic flexor tenosynovitis and septic arthritis and risk of opioid overuse following diagnosis: A registry-based nationwide retrospective cohort study in sweden. BMJ Open, 16(1), e108329. https://doi.org/10.1136/bmjopen-2025-108329
Althobaiti, A. S., Alkhadidi, S. J., Alhumyani, S. A., & Algethami, A. (2025). Prevalence of musculoskeletal disorders among people living with type 2 diabetes in the western region of saudi arabia: A cross-sectional study. Cureus, 17(8), e91111. https://doi.org/10.7759/cureus.91111
Kuşcu, B., & Gürbüz, K. (2025). A cost analysis of diabetic hand infections: A study based on direct, indirect, and one-year follow-up costs. Healthcare (Basel, Switzerland), 13(15). https://doi.org/10.3390/healthcare13151826
Schroeder, P. B., Hutto, W. M., Leggit, J. C., & Parker, C. H. (2020). Ultrasound use and outpatient management for pyogenic flexor tenosynovitis: A case report. Current Sports Medicine Reports, 19(6), 199–201. https://doi.org/10.1249/JSR.0000000000000717
Rosskopf, A. B., Martinoli, C., Sconfienza, L. M., Gitto, S., Taljanovic, M. S., Picasso, R., & Klauser, A. (2021). Sonography of tendon pathology in the hand and wrist. Journal of Ultrasonography, 21(87), e306–e317. https://doi.org/10.15557/JoU.2021.0052
Schwanz, K. L., & Senk, A. M. (2024). A positioning approach to upper extremity sonographic evaluation and intervention. Muscle & Nerve, 70(3), 302–305. https://doi.org/10.1002/mus.28190
Hubbard, D., Joing, S., & Smith, S. W. (2018). Pyogenic flexor tenosynovitis by point-of-care ultrasound in the emergency department. Clinical Practice and Cases in Emergency Medicine, 2(3), 235–240. https://doi.org/10.5811/cpcem.2018.3.37415
Tamai, M., Grundeken, V., Arima, K., Brinck, R. T., Mil, A. H. M. van der H., Ohki, N., Uetani, M., & Kawakami, A. (2023). Predictive value of magnetic resonance imaging-detected tenosynovitis of the metacarpophalangeal and wrist joints for the development of rheumatoid arthritis among patients with undifferentiated arthritis. Internal Medicine (Tokyo, Japan), 62(16), 2329–2334. https://doi.org/10.2169/internalmedicine.0077-22
Yi, Z., Zhuang, N., Ma, E., Yin, R., Zhang, Y., Zhao, C., Wang, F., Lv, H., Xie, L., Tian, Y., Sun, D., Li, T., & Xie, H. (2026). Enhancing tenosynovitis diagnosis with XGBoost: A machine learning approach using ultrasound data. Ultrasound in Medicine & Biology. https://doi.org/10.1016/j.ultrasmedbio.2026.05.012
Smolen, J. S., Landewé, R. B. M., Bergstra, S. A., Kerschbaumer, A., Sepriano, A., Aletaha, D., Caporali, R., Edwards, C. J., Hyrich, K. L., Pope, J. E., Souza, S. de, Stamm, T. A., Takeuchi, T., Verschueren, P., Winthrop, K. L., et al. (2023). EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Annals of the Rheumatic Diseases, 82(1), 3–18. https://doi.org/10.1136/ard-2022-223356
Bell, R. J., Cervenak, R., Flint, M. I., Perrins, G. E., Dickinson, A., Ghosh, A., & Umarji, S. (2025). The use of steroid injections for hand and wrist pathologies. Cureus, 17(11), e97104. https://doi.org/10.7759/cureus.97104
Pathuri, M., Bhatt, R. H., Stepan, J. G., Wolf, J. M., & Strelzow, J. A. (2025). Efficacy of low-dose versus high-dose corticosteroid injections for soft tissue pathology of the hand. The Journal of Hand Surgery, 50(12), 1483–1490. https://doi.org/10.1016/j.jhsa.2025.09.014
Frenkel Rutenberg, T., Ben Uri, A., Slevin, O., Kosashvili, Y., Atlan, F., & Daniel Iordache, S. (2024). Antibiotic treatment for pyogenic flexor tenosynovitis following animal bites. The Israel Medical Association Journal : IMAJ, 26(5), 304–308.
Gutowski, K. A., Ochoa, O., & Adams, Jr., William P. (2002). Closed-catheter irrigation is as effective as open drainage for treatment of pyogenic flexor tenosynovitis. Annals of Plastic Surgery, 49(4), 350–354. https://doi.org/10.1097/00000637-200210000-00003
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Krzysztof Hober, Monika Łapot, Mateusz Skowron, Wiktoria Skowron , Patrycja Szwemińska, Dominika Krupnik, Wiktoria Bzdak, Wojciech Neumann, Joanna Górak
This work is licensed under a Creative Commons Attribution 4.0 International License.
All articles are published in open-access and licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0). Hence, authors retain copyright to the content of the articles.
CC BY 4.0 License allows content to be copied, adapted, displayed, distributed, re-published or otherwise re-used for any purpose including for adaptation and commercial use provided the content is attributed.
