Infectious and Inflammatory Flexor Tenosynovitis Treatment & Management

Prompt medical management of acute nonsuppurative flexor tenosynovitis may preclude the need for surgical intervention.

• If a patient presents very early with suspected infectious FT, medical treatment may initially include intravenous antibiotics. Empiric antibiotics for penetrating trauma include the following:

  • Otherwise healthy individuals - Cefazolin 1-2 gm IV q6-8h; if penicillin-allergic, clindamycin 600-900 mg IV q8h or erythromycin 500-1000 mg IV q6h
  • Immunocompromised individuals - Ampicillin-sulbactam 1.5-3 gm IV q6h, or Cefoxitin 2 g IV q6-8h; if penicillin-allergic, clindamycin 600-900 mg IV q8h plus levofloxacin 500 mg IV qd (for adults) or clindamycin plus TMP/SMX (for children)
  • Bite wound - Same as immunocompromised individual (See above.)Splinting - In "safe position"
• Elevation - Initially until infection is under control
• Rehabilitation - Digital range of motion (ROM) exercises and antiedema control initiated once flexor tenosynovitis is under control

For patients who are immunocompromised or have diabetes, early surgical intervention is warranted. If medical treatment alone is attempted, then inpatient observation for at least 48 is indicated. Surgical drainage is necessary if no obvious improvement has occurred within 12-24 hours.

Nonoperative management is the primary treatment for inflammatory FT. In patients refractory to at least 3-6 months of good medical management or in patients with tendon ruptures, flexor tenosynovectomy should be performed.

The mainstay of therapy for FT caused by overuse syndromes is ceasing the insult by modifying activity. Ice and elevate the affected area, and administer a nonsteroidal anti-inflammatory drug (NSAID) if tolerated by the patient. Consider a short course of oral steroids. Flexor tendon sheath or carpal tunnel corticosteroid injections can decrease pain and the inflammatory response. If splinting is utilized, it should limit the area to pain-free ROM. Slow rehabilitation prevents reinitiation of the inflammatory phase. Use caution with corticosteroid injections, as they are detrimental if injected directly into the tendon or ligament. Multiple injections also can weaken the tendon and lead to rupture in patients with diabetes or inflammatory arthritis. Therefore, corticosteroid injections are used judiciously, especially in patients with diabetes and those with rheumatoid arthritis. Also, use of injectable or oral steroids is contraindicated if infectious FT has not been completely ruled out.

Treatment for rheumatoid inflammatory FT includes ice, NSAIDs, rest, splinting, hydroxychloroquine, gold, penicillamine, and methotrexate. Persisting cases may require oral steroid treatment. For acute flares of FT patients with rheumatoid arthritis, corticosteroid injections may provide prompt relief. Limit injections to avoid tendon rupture.^[37]

Several surgical approaches can be used to drain infectious FT. The method used is based upon the extent of the infection. The Michon classification scheme can be a helpful guide.

Table. Michon Classification Scheme (Open Table in a new window)

Most current recommendations for stage I and stage II infections advocate proximal and distal incisions for adequate drainage and irrigation.

Infectious flexor tenosynovitis

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 No. 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 awaiting culture results. (See Medical therapy.)

Some 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. Continuous irrigation with sterile saline at 25 mL/hr or intermittent irrigation every 2-4 hours with 25-50 mL of sterile saline are equally effective.^{[38, 39, 40]}

Indications for open tendon sheath debridement include stage III infections, chronic infections, or infections caused by atypical mycobacteria. 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 while preserving 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 debridement are necessary.

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

Inflammatory flexor tenosynovitis

For inflammatory FT infection, extensive volar Brunner incisions are used. The diseased tenosynovium is excised while carefully preserving the annular pulleys.

In the case of infectious FT, approximately 48 hours after surgery, remove the dressing, splint, and drains, and inspect the wounds. Initiate active and passive ROM exercises as well as soaks or whirlpool treatments. Usually a removable splint is fabricated and elevation is continued. For persisting infection, repeat operative debridement may be required. Intravenous antibiotics should continue for an additional 48-72 hours. Length of IV antibiotic treatment is determined by the culture and sensitivity results and specific patient factors. The switch from IV to oral antibiotics should be based not only on the culture results but also on the clinical examination and patient progress. Oral antibiotics should be continued for 5-14 days, depending on the following:

• Intraoperative findings
• Comorbidities
• Organism isolated
• Response to therapy

Generally the wounds should be left open so they can heal promptly by secondary intention. Delayed primary closure is not needed.

During the postoperative course of tenosynovectomy due to inflammatory FT, remove bandage, splint, and drain (if used) at 24-48 hours postsurgery. At that time, an intrinsic plus resting splint is fabricated. Wounds are fully closed at the time of the index procedure. Sutures can be removed 7-14 days postoperatively, depending on the condition of the rheumatoid skin.

For infectious FT, provide follow-up 72 hours after IV antibiotics have been stopped to ensure that the oral regimen is adequate and that no relapse of infection has occurred. Follow-up should continue until the infection has resolved, the wounds are closed, and full motion has returned. Monitor the patient until pain-free motion and strength have been maximized.

For inflammatory FT, hand therapy is started at 24-48 hours after the procedure and should consist of gentle, active ROM exercises, along with swelling and pain modalities. Near-full active ROM can be achieved by around 3 weeks; then, cautious strengthening can be added. However, it is not uncommon for progress to be slow, resulting in a rehabilitation course lasting 3-4 months.

For excellent patient education resources, visit eMedicine's Hand, Wrist, Elbow, and Shoulder Center, Arthritis Center, and Infections Center. Also, see eMedicine's patient education articles Tendinitis and Rheumatoid Arthritis.

The most common complication is loss of range of motion secondary to adhesions. If loss of functional motion persists, tenolysis is considered at 4 months postsurgery. One study showed improvement between the 6-week postoperative evaluation and 3-month follow-up.

The second major complication is soft tissue necrosis, which is more commonly seen in patients with delayed presentation or in those with diabetes.

For inflammatory flexor tenosynovitis, flexor tendon rupture is a potential complication.

Cases of infectious FT that present early and have no comorbidities have a good prognosis. Patients that present with fulminant infection, those with chronic infections, and those with impaired immune status all have increased risk of long-term complications and impairment.

Infectious flexor tenosynovitis remains an orthopedic emergency. Many advocate early surgical therapy for all cases. The literature clearly shows 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 and II infections, the authors advise proximal and distal incisions with sterile saline intraoperative irrigation in conjunction with empiric IV antibiotics. The authors prefer repeat surgical irrigation and debridements rather than postoperative indwelling catheter irrigation.

Strong evidence and agreement exist for open treatment of stage III infections. Some physicians still advocate radical tenosynovectomy for M ycobacterium infections, while others adhere to partial tenosynovectomy with a multiple antibiotic regimen and close observation. The devastating potential complication of infectious flexor tenosynovitis warrants prompt aggressive treatment.