Progressive flexor tendon sheath infection on hand after needle puncture during surgery: a case report

INTRODUCTION: Flexor tendon sheath infection may be due to trauma, laceration, or bites, commonly directly inoculating the sheath. Kanavel cardinal signs in flexor tendon sheath infection cases consist of symmetrical swelling of the entire digit, a digit with semi-flexed posture, exquisite tenderness along the course of the tendon sheath, and pain with attempted passive extension of the digit. Elevated levels of inflammation markers such as white blood cell count, erythrocyte sedimentation rate, and C-reactive protein are often found in such cases. Flexor tendon sheath infections require immediate diagnosis and treatment to prevent poor clinical outcomes. This paper reports one case of severe flexor tendon sheath infection with poor outcomes that required ray amputation of the affected finger. CASE PRESENTATION: A 35-year-old Sundanese male presented to the emergency department with right middle finger pain accompanied with swelling, blister, and blackened color 24 hours after accidental puncture by suture needle during gynecologic surgery. The patient was a resident physician of the obstetrics/gynecology department. The finger was necrotic with blisters at the proximal phalanx of the palmar aspect. Both the palmar and the dorsal aspects of the hand were swollen and inflamed, with firmer swelling on the dorsal part. The necrotic area had extended to the middle phalanx. The patient has been diagnosed with flexor tendon sheath infection with compartment syndrome. Immediate surgical debridement and fasciotomy with shoelace technique at the distal interphalangeal joint were performed. On the initial presentation, erythrocyte sedimentation rate, white blood cell count, and C-reactive protein were elevated. Smear culture was negative. A clear boundary of necrosis at the level of the middle phalanx of the right middle finger was found; subsequently, disarticulation at the level of the distal phalanx was performed. A ray amputation was performed to preserve the hand’s function for performing surgeries in the future. CONCLUSION: Prompt diagnosis and treatment of flexor tendon sheath infection are required to prevent complications. Progressive inflammation around infected soft tissue due to untreated tenosynovitis may lead to poor outcomes and may lead to the amputation of the affected finger. This condition may occur even in medical professionals; as such, awareness for proper protection during any medical procedure and prompt treatment-seeking are encouraged.