Synovitis

Historical Overview

• Synovitis of the hand or wrist is the inflammation of the synovial membrane lining these joints, which leads to painful symptoms and can cause permanent joint damage.^1,2

Description

• A comprehensive physical examination can be performed to assist in the diagnosis of hand or wrist synovitis.

Pathophysiology

• Synovitis is a generalized response of the synovial lining to a local problem, such as an injury or infection. Wrist synovitis most commonly occurs secondary to rheumatoid arthritis (RA), but it may also develop in patients with conditions like Reiter’s disease and Crohn’s disease.
• In younger individuals and when there is no underlying disease, hand and wrist synovitis may be associated with an overuse injury, especially in athletes involved in sports that are demanding on the wrists, like tennis and gymnastics.^1,2
• In RA, joint involvement starts with synovial hyperplasia that progresses to synovitis and pannus formation, a highly cellular inflammatory tissue.³
  • Synovitis behaves as a trigger to joint destruction in most cases of RA, and as it progresses, manifestations include joint pain, stiffness, swelling, and tenderness. If left untreated, it can eventually lead to permanent joint damage, all of which can severely reduce patients’ quality of life.¹

Instructions²

1. Obtain an accurate and complete patient history.
2. Perform a comprehensive physical examination of the patient’s hands and wrists, taking particular note of any swelling or redness.
3. Measure the patient’s wrist circumference just distal to the styloid process.
4. Assess the patient’s active range of motion (ROM) with a goniometer, as measured between the little metacarpal and forearm.
5. Measure the patient’s grip strength using an electronic instrument.
6. Ask the patient to self-evaluate their pain and function with questionnaires.

Related Signs and Tests

• MRI
• Ultrasound
• X-ray
• C-reactive protein test
• Erythrocyte sedimentation rate

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• A positive result occurs when the patient displays classic synovitis signs and abnormal values for wrist circumference, active ROM, grip strength, pain, and/or function.

• A negative result occurs when the patient does not display any notable signs and has normal values for active ROM, grip strength, pain, and/or function.

• Articular involvement of the hand and wrist is the presenting site in ~70% of patients with RA and frequently reflects the patient’s overall disease condition.³
• While conventional radiography can only evaluate joint space changes, osteoporosis, and erosive lesions, MRI evaluates bone lesions (edema, cysts, and erosions), depicts inflammatory synovium in joints and tendon sheaths, and distinguishes between active inflammatory and chronic fibrotic synovial tissue. This generally makes MRI more effective for diagnosing synovitis.³

1. Kobayashi Y, Kamishima T, Sugimori H, et al. Quantification of hand synovitis in rheumatoid arthritis: Arterial mask subtraction reinforced with mutual information can improve accuracy of pixel-by-pixel time-intensity curve shape analysis in dynamic MRI. J Magn Reson Imaging2018. [Epub] PMID: 29493823
2. Weitoft T, Rönnblom L. Randomised controlled study of postinjection immobilisation after intra-articular glucocorticoid treatment for wrist synovitis. Ann Rheum Dis2003;62(10):1013-5. PMID: 12972485
3. Argyropoulou MI, Glatzouni A, Voulgari PV, et al. Magnetic resonance imaging quantification of hand synovitis in patients with rheumatoid arthritis treated with infliximab. Joint Bone Spine2005;72(6):557-61. PMID: 16376805