For healthcare professionals only

Endgames Case Report

A painful swollen finger

BMJ 2012; 344 doi: (Published 06 June 2012) Cite this as: BMJ 2012;344:e3441
  1. Nada Al-Hadithy, specialist trainee year 4, plastic surgery1,
  2. Anna Panagiotidou, specialist trainee year 3, orthopaedic surgery2,
  3. Stuart Hamilton, consultant plastic and reconstructive surgeon3
  1. 1St John’s Hospital, Plastic Surgery Department, Livingston EH54 6PP, UK
  2. 2Royal National Orthopaedic Hospital, Trauma and Orthopaedics, London, UK
  3. 3St John’s Hospital, Plastic and Reconstructive Surgery Department, Livingston, UK
  1. Correspondence to: N Al-Hadithy nadaucl{at}

A 44 year old right hand dominant gardener presented to the emergency department with a two day history of a painful right ring finger. On closer questioning he had been weeding and pruning three days before presentation. He had not been wearing gloves but could not recall any unusual event. He had no relevant medical history.

On examination, the ring finger was swollen and tender along its length, with a blister on the radial aspect. The finger was warm compared with his other fingers, and capillary refill was less than 2 seconds. The finger was kept in flexion at the proximal interphalangeal and metacarpophalangeal joints and passive stretch caused intense pain.


  • 1 What is the diagnosis?

  • 2 What is the pathophysiology behind this condition?

  • 3 What are the common causative agents?

  • 4 How would you manage this patient?

  • 5 What are the sequelae of complications?


1 What is the diagnosis?

Short answer

Flexor sheath infection, also known as infectious flexor tenosynovitis or pyogenic tenosynovitis

Long answer

Infectious flexor tenosynovitis is the inoculation of an infectious agent within the enclosed space of the flexor sheath and multiplication of the organism in the culture rich synovial medium.1

Diagnosis is made by history and clinical examination to elicit Kanavel’s signs (fig 1).

Fig 1 Clinical image of swollen painful right ring finger

Kanavel’s signs include2:

  • Hand held in position of comfort, with the appearance of a relaxed hand cascade

  • Fusiform swelling

  • Tenderness along the flexor tendon or palmar aspect of the finger

  • Intense pain on passive stretch of the digit.

Intense pain on passive stretch is the most clinically reproducible of these four signs,3 4 with tenderness along the tendon sheath being the second most reproducible.5

The presence of all four signs is pathognomonic of pyogenic flexor tenosynovitis. However, a recent study showed that all …

View Full Text

Log in

Log in through your institution


* For online subscription