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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Hand infection and flexor-sheath infection

Musculoskeletal medicine and orthopaedics · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Deep hand infection is a function-threatening surgical emergency

Flexed posture, fusiform swelling, exquisite tenderness along a flexor sheath and pain on passive extension suggest pyogenic flexor tenosynovitis; systemic toxicity, rapidly spreading pain, bullae, crepitus, necrosis, compartment tension or neurovascular deterioration indicates deep, necrotising or septic progression.

Action: Use ABCDE, obtain immediate senior hand-surgical and microbiology input, remove rings, elevate and splint in a position of safety, take blood and deep cultures without delaying treatment, start exposure-appropriate intravenous antimicrobials, and proceed urgently to exploration, irrigation and debridement when deep infection is suspected.

Synopsis

Recognise superficial and deep hand infection early, identify pyogenic flexor tenosynovitis and bite-related contamination, resuscitate sepsis, protect hand function, obtain meaningful cultures, and secure urgent surgical source control without imaging delay.

  • A hand infection is an anatomical diagnosis: decide whether disease is superficial, abscessed, within a tendon sheath, joint, bone or deep fascial space and whether tissue or perfusion is threatened.
  • Flexor-sheath infection is suggested by flexed rest posture, fusiform swelling, sheath tenderness and pain on passive extension; absence of one sign does not safely exclude early disease.
  • First-line assessment is ABCDE plus complete hand examination after removing rings: wounds, spread, posture, active tendon function, passive-stretch pain, sensation, capillary refill and pulses.
  • Obtain FBC, CRP, renal and liver profile, glucose and lactate according to severity; take blood cultures in sepsis and deep tissue or fluid cultures at surgery, but do not delay antibiotics in an unstable patient.
  • Plain radiographs are first-line imaging for gas, foreign body, fracture and late bone change; ultrasound may identify fluid, but neither normal imaging nor blood tests excludes early sheath infection.
  • First-line emergency management is elevation, a safe-position splint, fasting, analgesia, tetanus and bite assessment, immediate hand-surgical review and prompt exposure-appropriate intravenous antibiotics.
  • Urgent operative irrigation and debridement is the treatment of choice for pyogenic flexor tenosynovitis with progression, deep-space abscess, necrosis, joint penetration or failed very-early supervised treatment; imaging must not postpone theatre.
  • Human and animal bites require irrigation, exploration when deep penetration is possible and co-amoxiclav unless unsuitable, usually 3 days for prophylaxis or 5 days for treatment, extended after review when tissue destruction or deep structures are involved.
  • Repeat examination after resuscitation and surgery, track erythema and neurovascular findings, review cultures daily and narrow antibiotics with microbiology while starting protected hand therapy as soon as source control permits.

Key red flags

The four high-yield flexor-sheath features are a flexed resting digit, fusiform swelling, tenderness along the whole sheath and marked pain on passive extension; incomplete sets still require urgent review.

Hypotension, tachypnoea, altered mental state, mottling, oliguria or raised lactate indicates sepsis and demands immediate resuscitation and antimicrobial treatment.

Pain out of proportion, rapid progression, skin anaesthesia, bullae, dusky change, crepitus or gas on imaging suggests necrotising infection requiring immediate surgical exploration.

A clenched-fist human bite over a metacarpophalangeal joint may penetrate tendon and joint despite a tiny wound and requires urgent specialist washout assessment.

A cool, pale or congested digit, delayed refill, new sensory deficit or tense compartment suggests vascular compromise or compartment syndrome and requires emergency surgery.

Investigation priorities

01
First-line ABCDE and anatomical hand examinationFirst stepFirst line

Identify sepsis, threatened perfusion and the infected compartment before tests or imaging consume time.

02
First-line blood assessment for significant infectionFirst line

Measure FBC, CRP, renal and liver function, glucose and lactate for severity, host risk and antimicrobial safety.

Management branches

ImmediateResuscitate and protect the hand

A deep hand infection, flexor-sheath infection, necrotising process or sepsis is suspected.

  1. Use ABCDE, obtain observations and intravenous access, treat shock and check glucose and lactate according to the sepsis pathway.
  2. Remove rings, elevate, mark spread, apply a safe protective splint, keep the patient fasting and give appropriate analgesia.
  3. Call senior hand surgery and microbiology immediately and arrange transfer if the receiving site lacks definitive hand cover.
  4. Take blood and appropriate cultures without delaying antibiotics, then start intravenous exposure-specific treatment promptly.

Key medicines

Intravenous flucloxacillin for severe clean-source infectionFor a severe clean-source staphylococcal or streptococcal hand infection, a common adult hospital regimen is flucloxacillin 2 g intravenously every 6 hours after cultures where possible; follow local microbiology advice and narrow to results.Use a different exposure-specific regimen for bites, water, injecting or MRSA risk; check immediate penicillin allergy, liver history, renal impairment, sodium load and interactions, and obtain specialist pregnancy advice.
Co-amoxiclav for adult hand bitesUse co-amoxiclav 250/125 mg or 500/125 mg orally three times daily for 3 days as prophylaxis or 5 days for treatment; extend to 7 days after review for significant tissue destruction or penetration of bone, joint, tendon or vascular structures. Use 1.2 g intravenously three times daily when oral treatment is unsuitable or severity requires admission.Avoid in serious penicillin allergy and previous co-amoxiclav jaundice or hepatic dysfunction, adjust for renal impairment, check anticoagulant interaction and pregnancy, and seek microbiology alternatives rather than using macrolide monotherapy for a deep bite.
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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • BOAST Management of Musculoskeletal Soft Tissue InfectionsUrgent assessment, antimicrobial timing, sampling and surgical source-control standards.
  • NICE NG184 Human and Animal Bites RecommendationsBite assessment, referral, first-choice antibiotic doses and course lengths.
  • NICE NG253 Managing Suspected SepsisAdult sepsis risk, investigations, antimicrobial timing and escalation.
  • NICE NG15 Antimicrobial Stewardship RecommendationsCulture review, documentation, narrowing and duration principles.
  • Flucloxacillin Summary of Product CharacteristicsParenteral and oral adult dosing, contraindications and safety.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom