Guidelines for Incision and Drainage in Tenosynovitis

Indications for Surgical Drainage

Incision and drainage is mandatory for confirmed or highly suspected infectious (pyogenic) tenosynovitis and forms the cornerstone of treatment – the procedure should be performed promptly to prevent tendon necrosis and systemic spread. 1
Immediate surgical drainage combined with intravenous antibiotics (e.g., vancomycin 15‑20 mg/kg every 8–12 h or an appropriate alternative) is recommended when pyogenic tenosynovitis is confirmed or strongly suspected. This regimen aims to eradicate the pathogen while relieving compartment pressure. 4

Systemic signs of toxicity (e.g., hypotension, altered mental status) are key indicators of infection and should trigger urgent surgical evaluation. 4
Fever exceeding 38.5 °C is an infection indicator in the initial assessment algorithm. 2
Heart rate greater than 110 beats/min supports suspicion of infection and warrants further work‑up. 2

Non‑infected tenosynovitis should be treated without incision and drainage; preferred measures include immobilization, NSAIDs for symptom control, and, when appropriate, corticosteroid injection. 1
Non‑steroidal anti‑inflammatory drugs (NSAIDs) provide symptomatic relief during the inflammatory phase of non‑infected tenosynovitis. 3

Performing incision and drainage on a non‑infected tendon sheath can lead to chronic fistula formation and prolonged morbidity. 1
Unnecessary surgical morbidity, including wound complications and postoperative pain, may occur when drainage is performed without infection. 2

Fine‑needle aspiration can be employed when the diagnosis remains equivocal after clinical examination and ultrasound; this technique obtains culture material while avoiding the morbidity of formal incision and drainage. 1
Intra‑articular corticosteroid injections should be avoided during the diagnostic work‑up if infection has not been definitively excluded, because steroids may exacerbate an underlying infectious process. 3