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.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
!
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.
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.
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.
Use ABCDE, obtain observations and intravenous access, treat shock and check glucose and lactate according to the sepsis pathway.
Remove rings, elevate, mark spread, apply a safe protective splint, keep the patient fasting and give appropriate analgesia.
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.
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.
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.