This is a catastrophic presentation of Stage III flexor tenosynovitis with septic necrosis of the tendons, likely progressed due to the combination of delayed presentation (5 days), diabetes (immunocompromised state leading to rapid progression), and signs of digital ischemia (cool finger, sluggish refill) which is a poor prognostic factor. The patient has several of the poor prognostic indicators identified by Pang et al.: age over 43, diabetes, digital ischemia, and delayed treatment beyond 24 hours. The intraoperative findings of grey, non-viable tendons indicate that we have missed the window for tendon preservation. My immediate intraoperative decision is whether this finger is salvageable at all. I would assess the extent of necrosis - is it confined to the flexor sheath or has it spread to involve the neurovascular bundles, bone, or joint? I would convert to a full open approach using either a mid-lateral or Bruner incision extending the full length of the finger to completely expose the sheath. I would perform extensive debridement removing all necrotic tissue - this includes excising the necrotic synovium, pulleys, and the dead portions of the FDP and FDS tendons. I would inspect the neurovascular bundles - if they appear healthy and perfusion improves after debridement, the finger may be salvageable as a stable, sensate post though without flexor function. If the vessels are thrombosed or the bone/joint is involved with osteomyelitis, amputation becomes the most appropriate option. The key principle is that trying to save dead tissue leads to ongoing sepsis and potentially systemic complications including septic shock. If I proceed with debridement and attempt salvage, I would leave the wound open, pack it loosely, and plan for repeat washouts every 48 hours until the tissue declares itself viable (typically 2-3 washouts). I would send all tissue for culture including fungal and atypical organisms and start broad-spectrum IV antibiotics - I would use vancomycin plus piperacillin-tazobactam to cover MRSA, streptococcus, and gram negatives, then de-escalate based on cultures. The patient and family need realistic counseling - even if we save the finger, he will have permanent stiffness, loss of flexion (no functioning flexor tendons), and may ultimately require delayed amputation if infection persists or the finger becomes a painful, useless burden. Future options after infection clears include two-stage flexor tendon reconstruction (Hunter rod then graft) but success rates are poor in diabetics with extensive scarring, or arthrodesis of IPJ joints in a functional position to give a stable post. This case highlights that flexor tenosynovitis is a surgical emergency - early recognition and treatment within 24 hours is critical, and delayed presentation especially in diabetics leads to devastating outcomes.