Flexor Sheath Infection

***Must inform registrar and/or consultant on-call***

introduction (1,2)

  • Surgical emergency
      • Pus in the flexor sheath (a closed compartment)
      • Usually due to S. aureus from penetrating injuries
  • Delayed treatment may lead to extension of infection into the hand and forearm with severe sepsis and permanent flexor injury
Image Reference: Orthobullet's "Pyogenic Flexor Tenosynovitis" Article. (2019)

Assessment (2)

  • Kanavel’s four cardinal sings (3) (patients may have 1 or all 4):
      • Severe pain on passive extension
      • Fusiform digital swelling
      • Finger held in a semi-flexed position
      • Tenderness along palpation of the flexor sheath

management (1,4)

  • NBM
  • IV Abx (consult local guidelines)
  • Pain relief
  • Immobilisation
  • Strict elevation in Bradford sling
  • Arrange urgent senior review


  • Early infection may respond to ‘closed drainage’ with small palmar and digital incisions in theatre to allow catheter insertion.

references

1. Chiu TW. Stone’s Plastic Surgery Facts: A Revision Guide, Fourth Edition. CRC Press; 2018. 2. Green DP, Wolfe SW. Green’s operative hand surgery. Elsevier/Churchill Livingstone; 2011. 3. Kennedy CD, Huang JI, Hanel DP. In Brief: Kanavel’s Signs and Pyogenic Flexor Tenosynovitis. Clin Orthop Relat Res. 2016 Jan;474(1):280–4. 4. Mamane W, Lippmann S, Israel D, Ramdhian-Wihlm R, Temam M, Mas V, et al. Infectious flexor hand tenosynovitis: State of knowledge. A study of 120 cases. J Orthop. 2018 Jun;15(2):701–6.
Image References:Header Image Reference: Licensed by Adobe Stock (2019)Digital Flexor Sheath Infection Image Reference: Orthobullet's "Pyogenic Flexor Tenosynovitis" Article. (2019)
This subpage has been reviewed by:
1) Mr. Martin Shapev - Plastic Surgery Registrar, RD&E (06/02/2020)