Management of infected flexor tendon injuries: A narrative review

Purpose: Flexor tendon injuries are a common result of trauma to the hand. The mechanisms of injury often result in open wounds with contamination and infection. The complications associated with infected wounds pose challenges to flexor tendon repair. Management entails adequate eradication of infection and tissue healing prior to tendon repair. Whilst guidelines exist for the management of flexor tendon injuries of the hand, the literature puts little emphasis on the management of these cases with the presence of concomitant infection. Creating clear outlines to adequately manage such cases would aid future management for optimal outcomes. Methods: A comprehensive search of literature was conducted. Articles published in English within the last 20 years were used. Results: Wounds with macroscopic wound contamination should receive empiric antibiotics. There is little evidence supporting prophylactic antibiotics. Pyogenic flexor tenosynovitis should be immediately taken to theatre. If possible, primary tendon repair is the ideal method of repair, however this is often limited by infection. The choice of secondary reconstruction depends on timing and extent of injury. If there is loss of nerve function, a tendon transfer is required. Tendon grafts are used in cases of loss of tendon length. A damaged tendon sheath requires two-stage tendon reconstruction. Conclusion: Infected wounds are a common complicating presenting factor in flexor tendon injuries. Empiric antibiotics in complex and contaminated wounds is essential. Primary tendon repairs have the best outcomes, however repair should be withheld until granulation tissue develops. Secondary repair options should be looked at on a case-specific basis.