PURPOSE: Tenosynovial fistulas in the palm are rare. If conservative treatment is unsuccessful, surgical treatment may include excision of the fistula and local flap coverage. In this article, I report 15 patients who were surgically treated for tenosynovial fistulas in the palm. METHODS: Between 1996 and 2009, I treated 15 patients for tenosynovial fistulas in the palm. There were 9 women and 6 men, with an average age of 42 years (range, 21-63 y). The index finger was involved in 5 patients, the long finger in 7, and the ring finger in 3. One patient had a fish fin injury, 6 had multiple surgeries for release of stenosing flexor tenosynovitis with intraoperative steroid injections, 1 had a pellet gun injury, and 7 had lacerations in the distal palm. Four patients had had unsuccessful closure of the fistula. All patients presented with a distal palm sinus draining clear frothy fluid. There were no signs of infection. Gram stains and cultures were negative. Smear and culture for Mycobacterium marinum were negative in the patient who had the fish fin injury. I tried conservative treatment in all patients for an average of 7 weeks. All patients were treated with excision of the sinus tract with partial resection of the A1 pulley and soft tissue coverage with a transposition flap. Pathological examination revealed epithelialization with nonspecific chronic inflammation. RESULTS: Postoperative follow-up averaged 59 months (range, 6-148 mo). All fistulas healed. Patients regained full range of motion and normal grip and pinch strength. One patient had transient tenderness of the scar for 3 months. There were no recurrences. CONCLUSIONS: Tenosynovial fistulas may develop after an injury to the flexor tendon sheath or following the use of steroids after release of trigger fingers recurring after an initial surgical release. Surgical treatment with excision of the fistula and local flap coverage yields excellent results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.