Limited Flexor Sheath Incision and Drainage in the Emergency Department in the Management of Early Pyogenic Flexor Tenosynovitis

Abstract

Background Pyogenic flexor tenosynovitis (PFT) has been considered a surgical emergency. Varying operative approaches have been described, but there are limited data on the method, safety, and efficacy of nonoperative or bedside management. We present a case series where patients with early flexor tenosynovitis are managed using a limited flexor sheath incision and drainage (I&D) in the emergency department (ED) to both confirm purulence within the flexor sheath and as definitive treatment. Methods A retrospective study of all patients clinically diagnosed in the ED with flexor tenosynovitis at our institution from 2012 to 2019 was performed. Patients with frank purulence on examination were taken emergently to the operating room (OR). Patients with equivocal findings underwent limited flexor sheath I&D in the ED. Safety and efficacy were studied for patients with early flexor tenosynovitis managed with this treatment approach. Results Thirty-four patients met the inclusion criteria. Ten patients underwent direct OR I&D, and 24 patients underwent ED I&D. In the ED I&D group, 96% (24 of 25) of patients did not have frank purulence in the flexor sheath and were managed with bedside drainage alone. There were no procedural complications and no need for repeat operative intervention. Time to intervention (3.1 hours vs 8.4 hours) was significantly shorter for the ED I&D group compared with the OR I&D group. Within the ED I&D group, 86% of patients exhibited good/excellent functional scores. Conclusions Limited flexor sheath I&D in the ED provides a potential safe and effective way to manage patients with early flexor tenosynovitis.

A Five-Year Retrospective Analysis of Diagnostic and Treatment Data of Flexor Sheath Infections: Can We Accurately Predict the Presence and Severity of Infection Prior to Surgical Washout?

“…One group reported a small case series on the use of limited flexor sheath washouts in the emergency department as an intervention used both to confirm purulence in the sheath and as a definitive treatment in some of their patients. Those who underwent a washout in the emergency department reported good functional outcomes [20]. Their study raises an interesting point: is there a role for limited incision or aspiration of the flexor sheath within the emergency department setting?…”