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. 
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.
Pharmacologic and Noninvasive Therapy
Infectious flexor tenosynovitis
Prompt medical management of acute nonsuppurative FT may preclude the need for surgical intervention. Nonoperative treatment for infectious FT includes the following:
IV antibiotics - May be included in initial treatment if the patient presents very early with suspected infectious FT
Elevation - Initially, until infection is under control
Splinting - In “safe position”
Rehabilitation - Digital range-of-motion (ROM) exercises and edema control, initiated once FT is under control
Empiric antibiotics for penetrating trauma include the following:
Otherwise healthy individuals - Cefazolin 1-2 g IV every 6-8 hours; if penicillin-allergic, clindamycin 600 mg IV every 8 hours or erythromycin 500-1000 mg IV every 6 hours
Immunocompromised individuals - Ampicillin-sulbactam 1.5-3 gm IV every 6 hours, OR cefoxitin 2 g IV every 6-8 hours; if penicillin-allergic, clindamycin 600 mg IV every 8 hours PLUS levofloxacin 500 mg IV once daily (for adults) OR clindamycin plus trimethoprim-sulfamethoxazole (TMP-SMZ) (for children)
Bite wound - Same as in immunocompromised individual
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 hours is indicated. Surgical drainage is necessary if no obvious improvement has occurred within 12-24 hours.
Admit the patient to the hospital with IV or intramuscular (IM) antibiotics (eg, ceftriaxone or spectinomycin). Surgical drainage may be indicated if antibiotic therapy does not significantly improve the patient’s condition within 48 hours.
Nongonococcal infectious tenosynovitis
If the diagnosis is equivocal, consultation with a hand specialist (eg, plastic surgery or orthopedics) and the use of elevation and broad-spectrum antibiotics that include staphylococcal coverage, streptococcal coverage, or both are necessary. Add anaerobic coverage if anaerobic infection is likely (ie, with cat or human bites). If the diagnosis of tenosynovitis is definite, refer the patient to a hand specialist for urgent surgical incision and drainage.
Inflammatory flexor tenosynovitis
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 cessation of the insult by modification of activity. Therapy also includes the following:
Icing and elevation of the affected area
Administration of a nonsteroidal anti-inflammatory drug (NSAID) if tolerated by the patient
Consideration of a short course of oral steroids
Administration of flexor tendon sheath or carpal tunnel corticosteroid injections to decrease pain and the inflammatory response
Splinting - If utilized, splinting should be limited in area to a pain-free ROM
Rehabilitation - 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 should be used judiciously, especially in patients with diabetes or rheumatoid arthritis. Also, the use of injectable or oral steroids is contraindicated if infectious FT has not been completely ruled out.
De Quervain tenosynovitis
Prescribe rest, NSAIDs, and a thumb spica wrist splint for patients with minimal symptoms. 
Peritendinous lidocaine-corticosteroid injection is considered by many to be the initial treatment of choice for de Quervain tenosynovitis. One review of the literature showed corticosteroid treatment to have a cure rate of greater than 80% and concluded that corticosteroid injection is safe.  (Surgical therapy is an option if conservative management fails.) 
A study examined injections of triamcinolone for de Quervain tenosynovitis and found an 89% efficacy rate for the drug.  In this report, patients could receive a maximum of three injections 2 weeks apart. A favorable result was measured by a questionnaire indicating no disruption in daily life.
One retrospective review concluded that in patients with more than minimal symptoms in de Quervain tenosynovitis, steroids are superior to NSAIDs and splinting. 
Volar flexor tenosynovitis
Peritendinous lidocaine-corticosteroid injection is the treatment of choice for volar FT (ie, trigger finger).  In a randomized trial, patients with this condition who were treated with corticosteroid injection showed a greater reduction in pain severity and frequency of triggering than did patients treated with placebo. The short-term effects were maintained during a 12-month follow-up phase. 
In a double-blind, randomized, controlled study from Taiwan that compared ultrasound-guided injection of hyaluronic acid with steroid injection in 36 patients with trigger finger (39 digits), Liu et al found the former treatment yielded promising results for the treatment of this condition, though optimal regimens remained to be defined. 
Treatment also includes activity modification (ie, avoidance of activities that cause triggering) and NSAIDs. Splinting is another treatment modality that has been studied. This is appropriate for patients who do not want to have a steroid injection.
Consider surgical tendon release if injection fails. Surgical release for trigger finger has success rates higher than 90%.
Treatment for rheumatoid inflammatory FT includes ice, NSAIDs, rest, splinting, hydroxychloroquine, gold, penicillamine, and methotrexate. Persistent cases may require oral steroid treatment. For acute flares of FT in patients with rheumatoid arthritis, corticosteroid injections may provide prompt relief. Limit injections to avoid tendon rupture. 
Drainage, Irrigation, and Tenosynovectomy
Choice of approach
Infectious flexor tenosynovitis
Several drainage techniques can be used in infectious FT. The choice of method is based on the extent of the infection. The Michon classification scheme can be a helpful guide in surgical intervention (see Table 1 below).
Table 1. Michon Classification Scheme (Open Table in a new window)
|Infection Stage||Characteristic Findings||Treatment|
|Stage I||Increased fluid in sheath, mainly a serous exudate||Catheter irrigation|
|Stage II||Purulent fluid, granulomatous synovium||Minimal invasive drainage +/- indwelling catheter irrigation|
|Stage III||Necrosis of the tendon, pulleys, or tendon sheath||Extensive open débridement and possible amputation|
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]
Indications for open tendon sheath débridement include the following:
Stage III infections
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 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.
Inflammatory flexor tenosynovitis
For inflammatory FT, extensive volar Brunner incisions are used. The diseased tenosynovium is excised, while the annular pulleys are carefully preserved.
Infectious flexor tenosynovitis
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 persistent infection, repeat operative débridement may be required. IV antibiotics should continue for an additional 48-72 hours; the length of IV antibiotic treatment is determined by the culture and sensitivity results and by specific patient factors. The switch from IV to oral antibiotics should be based not only on culture results but also on the clinical examination and patient progress. Oral antibiotics should be continued for 5-14 days, depending on the following:
Response to therapy
Generally, the wounds should be left open so they can heal promptly by secondary intention. Delayed primary closure is not needed.
Inflammatory flexor tenosynovitis
During the postoperative course of tenosynovectomy due to inflammatory FT, remove the patient’s bandage, splint, and drain (if used) at 24-48 hours post surgery. 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.
Consultations and referrals may include the following:
Primary care or hand specialty outpatient referral for follow-up care of de Quervain tenosynovitis and volar flexor tenosynovitis
Emergency medical or hand specialty consultation for suspected gonococcal tenosynovitis for hospital admission and IV antibiotics
Emergency hand specialty consultation for nongonococcal infectious tenosynovitis for hospital admission, IV antibiotics, and possible surgical drainage
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, after which time cautious strengthening can be added. However, it is not uncommon for progress to be slow, resulting in a rehabilitation course lasting 3-4 months. 
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