What are techniques for open tendon sheath débridement of infectious flexor tenosynovitis?

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

To expose the tendon sheath, a volar zigzag Brunner incision or a longitudinal midaxial incision is made. The midaxial incision is preferred because of postoperative coverage concerns. The thumb and small fingers are approached from the radial side; the other digits are approached from the ulnar side. The incision begins distally at the level of the A5 pulley, or just distal to the distal flexion crease, and is extended proximally to the web space. The incision is kept dorsal to the neurovascular bundle.

For extensive infections, the sheath may be opened at all of the cruciform pulleys with preservation of the annular pulleys, especially the A2 and A4 pulleys. If the small finger or thumb is involved and there is evidence of proximal involvement, an additional incision, proximal to the transverse carpal ligament, is made to ensure adequate drainage of the radial and ulnar bursae.

The sheath is copiously irrigated, and the wounds are left open with drains in place. Empiric antibiotics are started. The hand is dressed and splinted, and the wounds are reevaluated after 48 hours. If the infection has abated, the drains are removed and postoperative therapy is initiated. If the infection is not controlled, repeat irrigation and débridement are necessary.

For Mycobacterium species infection, extensive tenosynovectomy may be necessary, depending on the chronicity of infection.


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