Flexor Sheath Washout

Flexor Sheath Washout, pyogenic flexor tenosynovitis
Pyogenic flexor tenosynovitis. Image by Jonrako, Wikimedia Commons, CC BY-SA 4.0.

Indications

  • Pyogenic flexor tenosynovitis, Kanavel signs
  • Failure to improve within 24 hours of IV antibiotics
  • Kanavel signs are fusiform swelling, flexed posture, tenderness along the sheath and pain on passive extension
  • Early cases within 24 hours may settle with IV antibiotics, elevation and splinting
  • Diabetes, immunosuppression and delayed presentation favour early surgery

Position

  • Supine, arm table, tourniquet without exsanguination

Operative Steps

  1. Proximal incision over the A1 pulley to open the sheath
  2. Distal incision at the A5 pulley, midaxial or distal palmar
  3. Pass a fine catheter into the sheath proximally
  4. Irrigate with saline until clear from the distal incision
  5. Send fluid for culture, leave incisions open or loosely closed
  6. Open washout through a Bruner or midaxial incision for advanced infection with necrotic tissue
  7. Protect the neurovascular bundles and preserve the A2 and A4 pulleys
  8. Avoid high pressure irrigation that tracks into soft tissue

Postoperative Care

  • IV antibiotics, elevation and early motion
  • Repeat washout if not improving
  • Hand therapy within 24 to 48 hours to limit adhesions
  • Tailor antibiotics to cultures, Staph aureus is the usual organism
  • Review the wound daily for spreading infection

Complications

  • Tendon necrosis and adhesions
  • Stiffness
  • Amputation in delayed diabetic cases
  • Spread to the deep palmar spaces or a horseshoe abscess
  • Boutonniere or swan neck deformity from tendon loss

Related Pages

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.