Skip to content

Clinicians › Hand

Drainage of an Infected Flexor Sheath

51 citationsUpdated Oct 2026
Illustration: Drainage of an Infected Flexor Sheath

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Septic flexor tenosynovitis is a surgical emergency where prompt decompression is the treatment of choice for nearly all cases [1]. Expediency in treatment potentially improves final motion and function [1], as hand infections are associated with a high rate of complications that are often difficult to manage [16]. The standard of care involves a combination of surgical intervention, specifically incision and drainage, and appropriate antibiotic therapy tailored to the organism and infection severity [19]. Surgical drainage is the optimal treatment for any hand infection [6], with the real effectiveness of pyogenic tenosynovitis treatment lying in the through-and-through mechanical lavage of the tendon sheath [17].

Operative strategies vary based on acuity and severity. Early treatment of acute suppurative flexor tenosynovitis with limited incisions, catheter irrigation, and systemic antibiotics generally results in successful resolution of infection and return of digital motion [3]. A single open debridement with irrigation and primary wound closure followed by 10 days of antibiotic therapy has resolved uncomplicated pyogenic flexor tenosynovitis [2]. For early cases, limited flexor sheath incision and drainage in the emergency department provides a potential safe and effective management option [12], and the WALANT technique can be used for flexor tendon sheath incisions in the setting of infection [15]. Continuous catheter irrigation can effectively deal with infection of a silicone rod during two-stage flexor tendon reconstruction and maintain the reconstructed tendon sheath [10].

Outcomes are generally favorable, though residual deficits are common. Early diagnosis of purulent flexor tenosynovitis followed by drainage through small incisions and continuous postoperative irrigation appears to lead to the best functional outcome [8]. Use of antibiotics as a component of therapy resulted in improved range of motion outcomes in acute pyogenic flexor tenosynovitis [14], and using catheter irrigation rather than open washout resulted in improved range of motion outcomes in acute pyogenic flexor tenosynovitis [14]. Prompt antibiotic therapy with third-generation cephalosporins and surgical drainage leads to a good prognosis with full range of motion in gonococcal arthritis of the finger [9]. However, even otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection despite aggressive and prompt antibiotic therapy and surgical intervention [4]. The presence of pus within the flexor sheath is the only significant predictive factor for repeated flexor tendon washout [5].

Anatomy & Pathophysiology

Flexor Tendon Sheath Anatomy

The flexor tendon sheath constitutes a fibroosseous tunnel extending distally to the proximal aspect of the distal phalanx [65]. Within this structure, the flexor tendons run from the distal interphalangeal joint proximally to the A1 pulley [32]. The tenosynovium lining this tunnel supplies nutrition and lubrication to the poorly vascularized flexor tendons [65]. Tendon vascularity within the sheath is maintained via the vincula system, specifically the vinculum longus and brevis [65].

The annular pulleys are critical for mechanical function. The A1 pulley is located over the metacarpophalangeal joint [65], while the A5 pulley is located over the distal interphalangeal joint [65]. The A5 pulley is a discrete structure with a histologic composition consistent with that reported for other annular pulleys [92]. The A2 and A4 pulleys are the most essential in maintaining the mechanical advantage of the flexor tendons [65].

Bursal continuity dictates potential pathways for infection spread. The tenosynovial sheath of the flexor pollicis longus is continuous with the radial bursa [65], and the tenosynovial sheath of the little finger is continuous with the ulnar digital bursa [65]. In some patients, the radial and ulnar bursae communicate, allowing a horseshoe abscess to spread between the thumb and little finger if infection occurs in the flexor tendon sheath of either digit [65]. This communication occurs via Parona's space [32]. Furthermore, the radial and ulnar bursae extend up to the carpal tunnel in up to 80% of people [32].

Pathophysiology of Infection

Pyogenic flexor tenosynovitis is a closed-space infection of the flexor tendon sheath of the hand [37]. It is defined as a bacterial infection of the flexor tendon sheath between the visceral layer on the flexor tendon and the parietal layer [32]. The condition is most commonly associated with S. aureus after penetrating trauma [32]. While hematogenous spread can cause pyogenic flexor tenosynovitis, local inoculation via lacerations, puncture wounds, and bites are more common causes [37].

Infections can spread to the radial and ulnar bursae connections, with spread to small finger flexor tendon sheaths resulting in a horseshoe abscess [32]. Proximal spread of infection into Parona's space can also occur [32]. The resulting pus is a mixture of bacterial virulence factors, neutrophil-derived degranulation and netosis, dead and dying pathogens, defensive neutrophils, other immune cell types, and dead and dying host structural cells [18].

Digital pressures in patients with flexor sheath infections have been shown to reach over 30 mm Hg [47]. Digital pressures exceeding 30 mm Hg are sufficient to cause compartment syndrome even without excessive subcutaneous fluid infiltration [47]. If a catheter tip is not positioned within the flexor sheath and fluid is flushed into the tube, it accumulates within the subcutis [47]. Unrecognized subcutaneous fluid accumulation can cause pressure effects leading to vascular occlusion, distal ischemia, and soft tissue necrosis [47].

Delayed diagnosis of hand infections can result in amputation or death [41]. Despite aggressive and prompt antibiotic therapy and surgical intervention, otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection [4]. Severe infection can lead to impaired function or even amputation of the affected digit despite timely and thorough treatment [13].

Classification

Kanavel: The four cardinal signs of pyogenic flexor tenosynovitis include exquisite tenderness limited to the course of the sheath, a semiflexed position of the finger, exquisite pain on extension (most marked at the proximal end where swelling may be seen), and symmetrical swelling of the entire finger [32]. Not all signs are necessarily present; however, when flexor tenosynovitis is suspected, immediate treatment is required to prevent disastrous complications such as tendon adhesions or necrosis [32]. Uniform finger swelling may occur but does not distinguish pyogenic flexor tenosynovitis from other finger infections [34].

Michon and Loudon: Poor prognosis due to total peritenon failure with partially survived flexor tendons and tendinous adhesions is possible in the progressive stage of flexor tenosynovitis, defined as stage III in the Michon classification and stages III to IV in the Loudon classification [79].

Other Considerations: A three-tier clinical classification system based on preoperative assessment has been proposed to aid prognosis and treatment guidance for pyogenic flexor tenosynovitis of the upper extremity [38]. The number of Kanavel signs and symptom duration were significantly greater in the surgical management group compared with the early antibiotics-only group [78]. Patients with shorter symptom duration and fewer Kanavel signs were treated successfully with antibiotics alone [78]. Operatively confirmed flexor tenosynovitis presented more acutely with fewer days of symptoms and a higher number of Kanavel signs [78]. Patients with subacute presentations may represent inflammatory conditions rather than infection [78].

Clinical Presentation

Signs and Symptoms

Pyogenic flexor tenosynovitis is classically identified by Kanavel's four cardinal signs: exquisite tenderness limited to the course of the sheath, a semiflexed position of the finger, exquisite pain on extension (most marked at the proximal end where definite swelling often appears), and symmetrical swelling of the entire finger [32]. Not all of these signs are present in every patient [32]. While uniform finger swelling may occur, it does not distinguish pyogenic flexor tenosynovitis from other finger infections [34]. Some patients presenting without all four Kanavel signs have demonstrated ultrasound findings of fluid surrounding the tendon and purulence at operation [35].

In immunocompromised patients, the presentation may be more indolent and chronic, with a history of trauma that is remote or absent [33]. The site of penetrating trauma often appears relatively mild, resembling nothing more than a superficial scratch [33]. Atypical hand infections are difficult to recognize and treat due to their indolent nature and nonspecific symptoms [21]. Vascular malformations in tendon sheaths can also present as tenosynovitis, creating a diagnostic challenge [50].

Etiology and Microbiology

Pyogenic flexor tenosynovitis is most commonly associated with S. aureus following penetrating trauma [32]. Multiple series have identified Staphylococcus aureus as the most common pathogen in cultures [33]. Other commonly encountered pathogens include polymicrobial infections, methicillin-resistant S. aureus (MRSA), Staphylococcus epidermidis, Pseudomonas aeruginosa, and Streptococcus species [33]. Rare organisms isolated from cultures include Eikenella corrodens, Pasteurella multocida, Kingella kingae, Listeria monocytogenes, Neisseria gonorrhoeae, Clostridium difficile, and Mycobacterium species [33].

Local inoculation via lacerations, puncture wounds, and bites is a more common cause than hematogenous spread, though hematogenous spread can also cause the condition [37]. Mycobacterium heraklionense should be included in the differential diagnosis for chronic flexor tenosynovitis to minimize morbidity [28]. Atypical organisms such as Nocardia should remain in the differential diagnosis for soft tissue or tendon sheath infections that fail to respond to standard empiric antibiotics, particularly with environmental exposure [40]. Group A Streptococcus presents as isolated flexor tenosynovitis in developed countries, requiring swift identification to avoid serious complications [87].

Diagnostic Evaluation

Hand and upper-extremity infections are usually a clinical diagnosis, but imaging and laboratory evaluation aid in diagnosis [27]. Ultrasound is useful as a diagnostic tool for managing early pyogenic flexor tenosynovitis due to its excellent negative predictive value and specificity [51]. MRI may aid in the preoperative diagnosis of vascular malformations presenting as tenosynovitis [50]. A high index of suspicion coupled with an excellent knowledge of hand anatomy and function allows for an accurate diagnosis and effective management of deep space infections [24]. Early identification through appropriate laboratory testing is imperative for the eradication of the causative organism in atypical hand infections [21].

Investigations

Clinical Diagnosis and Examination

Clinical findings suggestive of the need for hospitalization include location of the bite over a joint or tendon sheath, erythema, pain, and swelling [48]. Early identification through appropriate laboratory testing and surgical treatment paired with medical management is imperative for eradication of the causative organism in atypical hand infections [21].

Imaging

Ultrasound: High resolution ultrasound offers a superior form of diagnostic imaging to MRI, in that preoperative or diagnostic aspirate can be performed [95]. Some patients presenting without all four of Kanavel's signs had the US finding of fluid surrounding the tendon and purulence at operation [35].

MRI: MRI may aid in preoperative diagnosis of vascular malformations in tendon sheaths that present as tenosynovitis [50]. In rare cases, imaging can demonstrate an underlying anatomical variant that may be a predisposing factor for flexor tenosynovitis [100].

Treatment

Non-Operative

Conservative management is not a standalone curative strategy for pyogenic flexor tenosynovitis; treatment requires a combination of surgical intervention and appropriate antibiotic therapy tailored to the organism and infection severity [19]. While early antibiotic administration may help prevent infection in patients with significant devitalized tissue or noncompliant follow-up [29], definitive eradication of the causative organism in atypical hand infections is imperative through surgical treatment paired with medical management [21].

Operative

Indications: Expediency in surgical treatment potentially improves final motion and function [1]. Early diagnosis followed by drainage through small incisions and continuous postoperative irrigation appears to lead to the best functional outcome [8].

Surgical Approach / Technique: A volar approach to the finger for pyogenic flexor tenosynovitis begins with outlining a Bruner zigzag incision along the entire finger [13]. Existing wounds or lacerations should be incorporated into the surgical incision [13]. The A1 pulley is released longitudinally to expose the flexor tendons, while the A5 pulley is released in a limited fashion [13]. Enveloping tenosynovitis or biofilm of the flexor tendons is debrided during the procedure [13]. The WALANT technique can be used for flexor tendon sheath incisions in the setting of infection [15].

Irrigation and Catheter Techniques: A 16-gauge angiocatheter needle is inserted antegrade at the level of the A1 pulley for irrigation [13]. The flexor sheath is repeatedly irrigated with antibiotic-impregnated irrigation until purulent fluid is cleared away [13]. The finger is passively flexed and extended throughout irrigation to maximize tendon irrigation [13]. The real effectiveness of treatment lies with the through-and-through mechanical lavage of the tendon sheath [17]. Continuous catheter irrigation without excisional debridement is a minimally invasive approach for managing flexor sheath infections [18]. Physiological fluid is delivered at a rate of 5–10 ml/hour by pump drivers during continuous catheter irrigation [18]. The hypothesis of continuous irrigation is to dilute pathogen virulence factors, neutrophil-derived inflammatory products, and necrotic material to favor immune mechanisms and provide decompression [18]. Two modifications have been described to simplify cannulation and passage of a fine feeding catheter for closed irrigation of infective flexor tenosynovitis [7]. The results of early treatment with limited incisions, catheter irrigation, and systemic antibiotics are generally good, with successful resolution of infection and return of digital motion [3].

Antibiotic Therapy: Management of pyogenic flexor tenosynovitis includes prompt administration of empirical intravenous antibiotics [37]. Use of antibiotics as a component of therapy resulted in improved range of motion outcomes [14].

Technical Safety and Cautions: It is imperative that the catheter tip is positioned within the flexor sheath to avoid potentially digit-threatening pressure necrosis [47]. If the catheter tip is not within the flexor sheath during continuous irrigation, fluid accumulates within the subcutis [47]. Unrecognized subcutaneous fluid accumulation during irrigation can cause vascular occlusion, producing distal ischemia and soft tissue necrosis [47]. Digital pressures of patients with flexor sheath infections have been shown to reach over 30 mm Hg, enough to cause compartment syndrome [47].

Outcomes and Complications: Despite aggressive and prompt antibiotic therapy and surgical intervention, even otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection [4]. Despite timely and thorough treatment, severe infection can lead to impaired function or even amputation of the affected digit [13]. Complication rates for pyogenic flexor tenosynovitis can be high, leading to impaired function and even amputation of the affected digit [37]. A one-stage tendon graft with flexor sheath dilatation using a Fogarty catheter may be considered when the flexor sheath is reasonably intact, potentially avoiding a two-stage procedure [26].

Complications

Other Considerations: Pyogenic flexor tenosynovitis can cause significant morbidity in the population despite adequate treatment [13]. Patients with suspected flexor tenosynovitis should be referred and treated early to avoid significant morbidity, especially when risk factors for poor prognosis are present [39].

Recovery

Light activity (weeks): The evidence does not specify a defined timeline for the resumption of desk work, driving, or light activities of daily living.

Full activity (months): No specific month range is provided in the evidence for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The evidence does not define a specific month range for the stabilization of pain, strength, or final functional outcomes.

Rehabilitation protocol: Uncomplicated pyogenic flexor tenosynovitis can be resolved with a single open debridement, irrigation, primary wound closure, and 10 days of antibiotic therapy [2]. For acute pyogenic flexor tenosynovitis, the use of catheter irrigation rather than open washout resulted in improved range of motion outcomes [14].

Functional milestones: Expediency in surgical decompression for septic flexor tenosynovitis may improve final motion and function [1]. The use of antibiotics as a component of therapy resulted in improved range of motion outcomes for acute pyogenic flexor tenosynovitis [14]. Prompt antibiotic therapy with third-generation cephalosporins and surgical drainage for gonococcal arthritis of the finger leads to a good prognosis with full range of motion [9].

Other Considerations: Despite adequate treatment, severe infection can lead to impaired function or even amputation of the affected digit [13]. The procedure described for stiffness of the proximal interphalangeal joints in rheumatoid arthritis can be expected to provide lasting benefit provided there is no recurrence of flexor tenosynovitis [20]. Delayed surgical debridement allows for less aggressive resection and good functional outcome in salvage of fingers after purpura fulminans [31]. Following flexor sheath infection leading to acute digital ischaemia, the stump healed uneventfully and remained satisfactory at one year [99].

Key Evidence

  • [L5] Surgical decompression is the treatment of choice for nearly all cases of septic flexor tenosynovitis, with expediency potentially improving final motion and function. [1] (10.1016/j.jhsa.2010.11.033)
  • [L4] A single open debridement with irrigation and primary wound closure followed by 10 days of antibiotic therapy resolved uncomplicated pyogenic flexor tenosynovitis. [2] (10.1007/s00402-016-2587-5)
  • [L5] The results of early treatment of acute suppurative flexor tenosynovitis with limited incisions, catheter irrigation, and systemic antibiotics are generally good, with successful resolution of infection and return of digital motion. [3] (10.1016/s0749-0712(21)00418-2)
  • [L5] Despite aggressive and prompt antibiotic therapy and surgical intervention, even otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection. [4] (10.5435/jaaos-20-06-373)
  • [Paper] The presence of pus within the flexor sheath is the only significant predictive factor for repeated flexor tendon washout. [5] (10.1055/s-0040-1715556)
  • [L4] Surgical drainage is the optimal treatment of any hand infection. [6] (10.1016/j.hansur.2020.12.011)
  • [L4] The authors describe two modifications to simplify cannulation and passage of a fine feeding catheter for closed irrigation of infective flexor tenosynovitis, aiming to ease the procedure and improve intrathecal lavage. [7] (10.1007/s11552-013-9591-9)
  • [L4] Early diagnosis of purulent flexor tenosynovitis followed by drainage through small incisions and continuous postoperative irrigation appear to lead to the best functional outcome. [8] (10.1177/1753193408087071)
  • [L5] Prompt antibiotic therapy with third-generation cephalosporins and surgical drainage leads to a good prognosis with full range of motion. [9] (10.1007/s00402-008-0727-2)
  • [L5] Continuous catheter irrigation can effectively deal with infection of a silicone rod during two-stage flexor tendon reconstruction and maintain the reconstructed tendon sheath. [10] (10.1055/s-0039-1688510)
  • [L4] Standard two-stage flexor tendon reconstruction is a reasonable option once the tuberculous infection has been adequately treated and is not associated with recurrence of that infection. [11] (10.1177/1753193409360604)
  • [L4] Limited flexor sheath I&D in the ED provides a potential safe and effective way to manage patients with early flexor tenosynovitis. [12] (10.1177/1558944721999729)
  • [Paper] [13] (10.1055/s-0039-1700370)
  • [L3] Use of antibiotics as a component of therapy resulted in improved range of motion outcomes, as did using catheter irrigation rather than open washout. [14] (10.1177/1753193415570248)
  • [L4] WALANT technique can be used for flexor tendon sheath incisions in the setting of infection. [15] (10.1177/15589447211030695)
  • [L5] Hand infections are associated with a high rate of complications that are often difficult to manage. [16] (10.1016/j.hcl.2020.03.010)
  • [L5] He concludes that the real effectiveness lies with the through-and-through mechanical lavage of the tendon sheath. [17] (10.1016/s0363-5023(79)80055-6)
  • [L5] [18] (10.1177/17531934231174819)
  • [L5] Treatment requires a combination of surgical intervention (incision and drainage) and appropriate antibiotic therapy tailored to the organism and infection severity. [19] (10.1016/j.jhsa.2014.03.031)
  • [L4] The procedure described can be expected to provide lasting benefit provided there is no recurrence of flexor tenosynovitis. [20] (10.2106/00004623-197658060-00010)
  • [L4] Atypical hand infections are difficult to recognize and treat due to their indolent nature and nonspecific symptoms; early identification through appropriate laboratory testing and surgical treatment paired with medical management is imperative for eradication of the causative organism. [21] (10.1016/j.jhsa.2025.09.023)
  • [L4] Prompt diagnosis and early debridement are of the utmost importance to improve outcomes for these often limb- and life-threatening infections. [23] (10.1177/17531934241268983)
  • [L5] A high index of suspicion coupled with an excellent knowledge of hand anatomy and function allows for an accurate diagnosis and effective management of deep space infections. [24] (10.1016/j.hcl.2020.03.014)
  • [L4] A one-stage tendon graft with flexor sheath dilatation using a Fogarty catheter may be considered when the flexor sheath is reasonably intact, even if narrowed by scar tissue, potentially avoiding a two-stage procedure. [26] (10.1054/jhsb.2002.0771)
  • [L5] Hand and upper-extremity infections are usually a clinical diagnosis, but imaging and laboratory evaluation aid in diagnosis. [27] (10.1016/j.hcl.2020.03.002)
  • [L5] Mycobacterium heraklionense should be included in the differential diagnosis for chronic flexor tenosynovitis to minimize morbidity. [28] (10.1016/j.jhsg.2021.12.010)
  • [L1] Early treatment with antibiotics may play a role in helping prevent infections of the fingers in patients who have significant amounts of devitalized tissue or who are noncompliant in follow-up care. [29] (10.1016/0363-5023(90)90152-h)
  • [L4] It may be time to abandon the standard approach and consider removing all the hardware at the time of infection. [30] (10.1007/s11999-007-0053-y)
  • [L4] Delayed surgical debridement allows for less aggressive resection and good functional outcome. [31] (10.1177/1558944716661996)
  • [L5] [32] (10.1016/j.jhsa.2011.05.035)
  • [L5] [33] (10.1007/s11999-015-4367-x)
  • [L4] Pyogenic flexor tenosynovitis may result in uniform finger swelling, but this does not appear to distinguish PFT from other finger infections. [34] (10.1016/j.jhsa.2019.01.013)
  • [L4] Some patients presenting without all four of Kanavel's signs had the US finding of fluid surrounding the tendon and purulence at operation. [35] (10.5811/cpcem.2018.3.37415)
  • [L5] [37] (10.1016/j.jhsa.2019.04.011)
  • [L2] The authors propose a three-tier clinical classification system based on preoperative clinical assessment to aid in prognosis and guidance in the treatment of pyogenic flexor tenosynovitis of the upper extremity. [38] (10.2106/jbjs.f.01356)
  • [L5] Patients with suspected flexor tenosynovitis should be referred and treated early to avoid significant morbidity, especially when risk factors for poor prognosis are present. [39] (10.1136/bcr-2012-006778)
  • [L4] Atypical organisms such as Nocardia should remain in the differential diagnosis of soft tissue or tendon sheath infections that fail to respond to standard empiric antibiotics, particularly with environmental exposure. [40] (10.1016/j.jhsg.2025.100934)
  • [L5] Early identification and treatment of hand infections are essential to achieve optimal outcomes, as delayed diagnosis can result in amputation or death. [41] (10.1016/j.jhsa.2018.05.027)
  • [L4] [47] (10.1177/1753193412446574)
  • [L3] Clinical findings suggestive of the need for hospitalization include location of the bite over a joint or tendon sheath, erythema, pain, and swelling. [48] (10.1016/j.jhsa.2013.11.003)
  • [L4] Vascular malformations in tendon sheaths can present as tenosynovitis, creating a diagnostic challenge; early diagnosis and treatment are necessary to prevent complications, and MRI may aid in preoperative diagnosis. [50] (10.1007/s11552-011-9384-y)
  • [L2] Ultrasound is useful as a diagnostic tool for managing early pyogenic flexor tenosynovitis thanks to its excellent negative predictive value and specificity. [51] (10.1016/j.hansur.2017.12.004)
  • [L4] The metal ear suction catheter is simple and effective for irrigation in flexor tenosynovitis, allowing insertion under direct vision without buckling. [54] (10.1177/1753193414522961)
  • [L4] [78] (10.1177/15589447211043187)
  • [Case_report] [79] (10.1007/s11552-013-9507-8)
  • [L4] This rare case highlights an epidemiological shift where Group A Streptococcus presents as isolated flexor tenosynovitis in developed countries, requiring swift identification to avoid serious complications. [87] (10.1177/17531934241286114)
  • [L5] The A5 pulley is a discrete structure, with measurements as noted as well as a histologic composition consistent with that reported for the other annular pulleys. [92] (10.1016/s0363-5023(98)80051-8)
  • [L5] High resolution ultrasound offers a superior form of diagnostic imaging to MRI, in that preoperative or diagnostic aspirate can be performed. [95] (10.1016/j.jhsa.2004.02.004)
  • [L4] The stump healed uneventfully and remained satisfactory at one year. [99] (10.1177/1753193409344504)
  • [L4] In rare cases, imaging can demonstrate an underlying anatomical variant that may be a predisposing factor. [100] (10.1055/s-0036-1597552)

See Also

References

[1] Septic Flexor Tenosynovitis. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2010.11.033

[2] Treatment of digital pyogenic flexor tenosynovitis: single open debridement, irrigation, and primary wound closure followed by antibiotic therapy. Archives of Orthopaedic and Trauma Surgery. 2016. DOI: 10.1007/s00402-016-2587-5

[3] PYOGENIC FLEXOR TENOSYNOVITIS. Hand Clinics. 1998. DOI: 10.1016/s0749-0712(21)00418-2

[4] Flexor Tendon Sheath Infections of the Hand. Journal of the American Academy of Orthopaedic Surgeons. 2012. DOI: 10.5435/jaaos-20-06-373

[5] Prognostic Factors for Repeated Flexor Tenosynovitis Washout: A Retrospective Study. Journal of Hand and Microsurgery. 2022. DOI: 10.1055/s-0040-1715556

[6] Advanced finger infection: more frequent than expected and mostly iatrogenic. Hand Surgery and Rehabilitation. 2021. DOI: 10.1016/j.hansur.2020.12.011

[7] Modifications to Simplify Intrathecal Irrigation for Pyogenic Flexor Tenosynovitis. HAND. 2014. DOI: 10.1007/s11552-013-9591-9

[8] Purulent Flexor Tenosynovitis: Factors Influencing the Functional Outcome. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193408087071

[9] An unusual case of gonococcal arthritis of the finger. Archives of Orthopaedic and Trauma Surgery. 2008. DOI: 10.1007/s00402-008-0727-2

[10] Continuous Catheter Irrigation for the Treatment of Purulent Tenosynovitis during Two-Stage Flexor Tendon Reconstruction. Journal of Hand and Microsurgery. 2019. DOI: 10.1055/s-0039-1688510

[11] Staged flexor tendon reconstruction in a patient with caseous tuberculous tenosynovitis. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193409360604

[12] Limited Flexor Sheath Incision and Drainage in the Emergency Department in the Management of Early Pyogenic Flexor Tenosynovitis. HAND. 2021. DOI: 10.1177/1558944721999729

[13] Pyogenic Flexor Tenosynovitis: Evaluation and Treatment Strategies. Journal of Hand and Microsurgery. 2019. DOI: 10.1055/s-0039-1700370

[14] A systematic review of the management of acute pyogenic flexor tenosynovitis. Journal of Hand Surgery (European Volume). 2015. DOI: 10.1177/1753193415570248

[15] Treatment of Pyogenic Flexor Tenosynovitis in the Emergency Department Setting With WALANT Technique. HAND. 2021. DOI: 10.1177/15589447211030695

[16] Complications of Hand Infections. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.010

[17] Two philosophies of pyogenic tenosynovitis treatment. The Journal of Hand Surgery. 1979. DOI: 10.1016/s0363-5023(79)80055-6

[18] Hand infection: a management approach based on a new understanding of combined bacterial and neutrophil mediated tissue damage. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231174819

[19] Acute Hand Infections. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.03.031

[20] Stiffness of the proximal interphalangeal joints in rheumatoid arthritis. The role of flexor tenosynovitis. The Journal of Bone & Joint Surgery. 1976. DOI: 10.2106/00004623-197658060-00010

[21] Atypical Hand Infections. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2025.09.023

[23] A surge in the incidence of invasive Group A Streptococcus hand infections: a single Hand Unit experience. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241268983

[24] Hand Abscesses. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.014

[26] Flexor Sheath Dilatation with a Fogarty Catheter. Journal of Hand Surgery. 2002. DOI: 10.1054/jhsb.2002.0771

[27] Imaging and Laboratory Workup for Hand Infections. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.002

[28] Flexor Tenosynovitis Caused by Mycobacterium heraklionense. Journal of Hand Surgery Global Online. 2022. DOI: 10.1016/j.jhsg.2021.12.010

[29] Role of antibiotics in open fractures of the finger. The Journal of Hand Surgery. 1990. DOI: 10.1016/0363-5023(90)90152-h

[30] Acute Infections After Fracture Repair. Clinical Orthopaedics & Related Research. 2008. DOI: 10.1007/s11999-007-0053-y

[31] Delayed Surgical Debridement and Use of Semiocclusive Dressings for Salvage of Fingers After Purpura Fulminans. HAND. 2016. DOI: 10.1177/1558944716661996

[32] Hand Infections. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.05.035

[33] In Brief: Kanavel's Signs and Pyogenic Flexor Tenosynovitis. Clinical Orthopaedics & Related Research. 2016. DOI: 10.1007/s11999-015-4367-x

[34] Radiographic Soft Tissue Thickness Differentiating Pyogenic Flexor Tenosynovitis From Other Finger Infections. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2019.01.013

[35] Pyogenic Flexor Tenosynovitis by Point-of-care Ultrasound in the Emergency Department. Clinical Practice and Cases in Emergency Medicine. 2018. DOI: 10.5811/cpcem.2018.3.37415

[37] Pyogenic Flexor Tenosynovitis: Evaluation and Treatment Strategies. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2019.04.011

[38] Factors Affecting the Prognosis of Pyogenic Flexor Tenosynovitis. The Journal of Bone & Joint Surgery. 2007. DOI: 10.2106/jbjs.f.01356

[39] Pyogenic flexor tenosynovitis leading to an amputation. BMJ Case Reports. 2012. DOI: 10.1136/bcr-2012-006778

[40] Soil to Sheath: Nocardia Flexor Tenosynovitis in an Immunocompetent Pottery Artist. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2025.100934

[41] Hand Infections. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.05.027

[47] Continuous flexor sheath irrigation: a cautionary tale. Journal of Hand Surgery (European Volume). 2012. DOI: 10.1177/1753193412446574

[48] Cat Bite Infections of the Hand: Assessment of Morbidity and Predictors of Severe Infection. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2013.11.003

[50] Vascular Malformation of the Flexor Tendon Presenting as Tenosynovitis. HAND. 2011. DOI: 10.1007/s11552-011-9384-y

[51] Usefulness of ultrasound for the diagnosis of pyogenic flexor tenosynovitis: A prospective single-center study of 57 cases. Hand Surgery and Rehabilitation. 2018. DOI: 10.1016/j.hansur.2017.12.004

[54] Simplifying irrigation in flexor tenosynovitis. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414522961

[65] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > FLEXOR TENDON INJURY.

[78] Antibiotics Versus Surgery in Treatment of Early Flexor Tenosynovitis. HAND. 2022. DOI: 10.1177/15589447211043187

[79] Two-Stage Tendon Sheath Reconstruction Using Sublimis Tendon and Silicone Penrose Drain after Severe Purulent Flexor Tenosynovitis: A Case Report. HAND. 2013. DOI: 10.1007/s11552-013-9507-8

[87] Streptococcus pyogenes flexor tenosynovitis. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241286114

[92] Anatomy and histology of the A5 pulley. The Journal of Hand Surgery. 1998. DOI: 10.1016/s0363-5023(98)80051-8

[95] Gouty flexor tenosynovitis of the digits: report of three cases. The Journal of Hand Surgery. 2004. DOI: 10.1016/j.jhsa.2004.02.004

[99] Flexor sheath infection leading to acute digital ischaemia. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193409344504

[100] Radial Artery Pseudoaneurysm with Aberrant Radial Artery Anatomy: An Unusual Presentation of Flexor Tenosynovitis. Journal of Hand and Microsurgery. 2016. DOI: 10.1055/s-0036-1597552

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.