Pyogenic Flexor Tenosynovitis: Modern Management Strategies and the Iatrogenic and Cognitive Drivers of Delayed Intervention

Pyogenic flexor tenosynovitis (PFT) remains one of the most challenging hand infections, capable of causing undesired subsequent events including severe functional loss and amputation. While Kanavel cardinal signs have historically guided diagnosis, recent evidence suggests they lack the specificity required for modern clinical decision-making. This review evaluates the current landscape of PFT management, comparing the efficacy of conservative antibiotic therapy against surgical intervention. We analyse large-scale data regarding prognosis, highlighting that treatment delays – often driven by cognitive biases such as loss aversion – significantly worsen outcomes. We propose an updated treatment algorithm that incorporates diagnostic aspiration to rule out mimics and mandates a strict 12- to 24-hour limit for conservative trials. Furthermore, we discuss the evolution of surgical techniques from open drainage to closed catheter irrigation and Continuous Local Antibiotic Perfusion (CLAP) for severe cases. Surgeons must view PFT not merely as an infection, but as a ‘compartment syndrome’ of the tendon sheath requiring urgent decompression to prevent irreversible sequelae. Level of Evidence: Level V (Therapeutic)