Flexor tendon phlegmons (infectious flexor tenosynovitis) – Therapy

Is it necessary to administer antibiotics when treating an infectious flexor tenosynovitis?

Yes. It is necessary. However, the antibiotic treatment is under no circumstances to be seen as replacement for a timely surgical intervention. The antibiotics will support the surgical therapy; they will not make it obsolete!

Only a surgical intervention at the opportune time will prevent severe damages in case of deeper-laying hand infections!

So when is the opportune time for surgery on an infectious flexor tenosynovitis?

Surgery on an infectious flexor tenosynovitis should take place as early as possible. To define “as early as possible”: As soon as a reliable diagnose can be confirmed would be the opportune time!

In the case seen here the infection had already spread into the forearm. At the time the surgery took place, the infected hand was extremely painful and hardly functional. Also, the patient was experiencing numbness in the fingers.

What happens if surgery takes place too late?

In these cases inflammations progressing far into the carpal tunnel and palm of the hand may be expected. In isolated cases a contagion through communicating interconnections of the flexor tendon sheaths in the carpal tunnel may spread into other fingers (this however, is not a very common phenomena anymore in today´s day and age).

What exactly is done during surgery?

The first step of the procedure consists of sharp debridement to remove the typically vast inflamed area from necrotic or semi-necrotic tissue, often found during surgery on flexor tendon phlegmons, using a zig-zag incision for distal and proximal elongation.

Pus and necrotic tissue have to be removed during surgery!

In advanced cases the necrotic tissue reaches all the way into the flexor tendons. In these cases not only the inflamed tendon sheath tissue has to be removed but also the affected areas of the actual flexor tendon. This however, will always lead to a loss of mobility.

Nevertheless the removal of necrotic tendon tissue unfortunately is not optional.

Only by removing all infected and necrotic tissue can a new flare up of the infection be avoided.

An additional measure practiced in connection with a surgical procedure on a flexor tendon is the use of surgical drainage to repeatedly provide irrigation to the entire tendon sheath after the surgery took place. Furthermore antibiotic-containing bead chains may be considered.

An antibiotic-containing bead chain consists of several small individual beads which are connected by a wire. While in place, the beads evenly emit an antibiotic agent into the tissue. The removal of the chain once the therapy is complete occurs through one tip of the guidewire which was left on the outside precisely for this purpose.

What type of anesthesia is advisable in connection with an infectious flexor tenosynovitis?     

The aforementioned surgical procedure (e.g. on a finger) cannot be performed under local anesthesia. Either a brachial plexus block is selected or general anesthesia.

Before opting for a plexus block, however, the anesthetist will have to check whether there is an inflammation of the lymphatic system, or, whether the lymph nodes are severely swollen. Should this be the case, numbing the nerve branches of the plexus will not suffice. In this case general anesthesia should be selected.

If a hand is severely inflamed, a brachial plexus block which requires the numbing of the nerve branches of the plexus, can only be applied if the lymph nodes in the armpit are not yet swollen.

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