What is the role of surgery in the treatment of infectious flexor tenosynovitis?

Updated: Nov 22, 2019
  • Author: Mark R Foster, MD, PhD, FACS; Chief Editor: Harris Gellman, MD  more...
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Most current recommendations for stage I and stage II infections advocate proximal and distal incisions for adequate drainage and irrigation.

The proximal incision is made over the A1 pulley. If the radial or ulnar bursa is the suggested point of tenosynovitis, make the incision just proximal to the transverse carpal ligament. In the digit, either a standard Brunner incision or a midaxial incision may be utilized.

The distal incision is made over the region of the A5 pulley. If utilizing the midaxial approach, the incision should be dorsal to the neurovascular bundle. A Brunner incision allows better initial exposure but may complicate closure/coverage if skin necrosis ensues and is more likely to interfere with therapy postoperatively.

A 16-gauge polyethylene catheter or a 3.5-5 French feeding tube then is inserted into the tendon sheath through the proximal incision. The sheath is copiously irrigated with a minimum of 500 mL of normal saline. Avoid excessive fluid extravasation into the digit because it can result in necrosis of the digit.

The catheter can be loosely sewn in or simply removed after irrigation. A small drain is placed in the distal incision, and the wounds are left open. A splint is applied, the hand is elevated, and the appropriate empiric antibiotic coverage is started while the clinician awaits culture results.

Some clinicians prefer the continuous irrigation technique over a period of 24-48 hours. The catheter is sewn in place, and a small drain is secured at the distal incision site. Either continuous irrigation with sterile saline at  a rate of 25 mL/hr or intermittent irrigation every 2-4 hours with 25-50 mL of sterile saline is equally effective. [36, 37, 38]

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