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Infectious Tenosynovitis: Closed Drainage


- Technique:
- goal is to establish closed continuous drainage thru flexor sheath; 
- tourniquet should be used; 
- incision & drainage of flexor tendon sheaths are performed from both proximal and distal ends; 
- palmar incision: 
- transverse incision is made just proximal to distal palmar crease, over the infected tendon; 
- spread thru the palmar aponeurosis; 
- make incision just proximal to A1 pully and enter into sheath; 
- distal incision: 
- finger incision may be made either dorslateral at level of middle phalanx or directly on palmar surface at this level; 
- incision can also be made in the distal flexor crease of digit; 
- distal sheath is exposed thru ulnar midaxial incision & opened; 
- enter sheath between annular pulleys, insert small catheter (size no. 5 Fr) 
- evaluation of flexor tendons: 
- flexor tendon may have to be excised; 
- after the infection has been eradicated and the wound closed, consider free tendon grafting and staged tendon reconstruction; 
- rebuild pulleys at the time of prosthesis insertion; 
- irrigation: 
- thread a soft catheter (No. 5 pediatric feeding tube) into distal incision; 
- alternatively, 16 ga. polyethylene catheter is inserted into sheath; 
- drain is brought out thru skin and the skin is loosely sutured; 
- irrigate w/ either sterile saline or sterile Ringer lactate solution; 
- sheath is irrigated with 25 to 50 ml of saline/hour; 
- antibiotics are not added to the fluid, since this might invite an additional inflammatory reaction in the sheath; 
- dressing should contain fluffed gauze and ADB pads to absorb fluid; - dressing is changed as needed