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Surgeon Reports on Rare Fistula of the Hand

In this report, a hand surgeon from the Southern Illinois Hand Center recaps his experience treating a rare fistula in the palm of 15 patients. All had either an injury to the palm or surgery with incision for trigger finger and steroid injections as the reason(s) or cause(s) allowing the problem to develop.

A fistula is an abnormal channel or passageway between two places that normally do not connect. In the case of these patients, the tract was from the lining around a tendon out through an opening in the skin. The opening between these two places allowed synovial fluid from inside the lining of the tendon to escape through a hole in the palm.

Patients with this problem had a frothy fluid draining from an opening called the sinus in the palm. The skin around the sinus was soft and breaking down described as a maceration. Pain, loss of motion, and decreased strength were also noted.

Treatment for the problem had been conservative (nonoperative) with antibiotics and immobilization in a splint. But the fistula did not heal and the problem continued. When these patients were referred to the Hand Center, they were tested for infection. No one had any infection.

The surgeon decided to remove the entire tract forming the fistula including the skin around the fistula's opening. A skin graft to cover the opening was required. Just removing the fistula and closing the opening does not work. The quality of the macerated skin around the opening did not allow it to be used. Complete healing of the fistula required fresh, undamaged skin.

And, in fact, all 15 patients had complete closure of the wound with this treatment approach. No one had a recurrence of the problem. Everyone regained full pinch and grip strength, normal sensation, and full motion. The only postoperative problems were temporary tenderness over the scar in one patient. That one person developed a thicker scar in the palm than the other patients. This particular patient had already had two previous surgeries (both simple fistula closures), which may have been contributing factors to the scarring.

The author advises other surgeons and physicians (especially emergency department personnel dealing with these kinds of issues) to perform this type of complete tract removal if and when a fistula develops in the hand. Conservative care can be tried but is not likely to take care of the problem. Based on his experience, a simple excision will also not provide adequate closure.

Reference: Nash H. Naam, MD. Flexor Tenosynovial Fistulas in the Palm. In The Journal of Hand Surgery. May 2012. Vol.37A. No. 5. Pp. 925-929.