What are the treatment options for tenosynovitis?

Updated: Aug 27, 2018
  • Author: Mark R Foster, MD, PhD, FACS; Chief Editor: Harris Gellman, MD  more...
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Answer

Nonsuppurative flexor tenosynovitis (FT) frequently is treated nonoperatively, but in chronic conditions, surgical intervention may be necessary. If the patient's overall medical condition may preclude the aggressive treatment of nonsuppurative FT, rely on medical management.

Infectious FT remains an orthopedic emergency. Many advocate early surgical therapy for all cases. The literature clearly shows, however, that medical treatment can be used initially for early, uncomplicated infections, but timing is controversial.

Some authors have used single-incision irrigation and drainage. For stage I (increased fluid in tendon sheath, mainly a serous exudate) and stage II (purulent fluid, granulomatous synovium) infections, the authors advise proximal and distal incisions, with sterile saline intraoperative irrigation in conjunction with empiric intravenous (IV) antibiotics. The authors prefer repeat surgical irrigation and débridement rather than postoperative indwelling catheter irrigation.

Strong evidence and agreement exist for open treatment of stage III (necrosis of the tendon, pulleys, or tendon sheath) infections. Some physicians still advocate radical tenosynovectomy for Mycobacterium infections, while others adhere to partial tenosynovectomy with a multiple antibiotic regimen and close observation. The devastating potential complication of infectious FT warrants prompt aggressive treatment.

Dailiana et al, in a retrospective study of 41 patients with purulent FT, found that the best functional outcome associated with this condition resulted from early diagnosis, drainage through small incisions, and continuous postoperative irrigation. Worse outcomes resulted in cases of delayed treatment and infections with specific pathogens. Staphylococcus aureus was detected in most cases. [26]

The indication for surgical drainage includes history and physical examination consistent with acute or chronic FT. In certain circumstances when acute FT presents within the first 24 hours of infection development, medical management may initially be used. Prompt improvement of symptoms and physical findings must follow within the ensuing 12 hours; otherwise, surgical intervention is necessary.


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