Updated: 5/15/2021

Felon

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  • summary
    • Felons are subcutaneous abscesses of the fingertip pulp.
    • Diagnosis is made clinically by assessing for tenderness, erythema and fluctuance of the fingertip pulp.
    • Treatment is usually I&D and IV antibiotics.
  • Epidemiology
    • Incidence
      • accounts for 15-20% of hand infections
    • Anatomic location
      • most commonly occurs in the thumb or index finger
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • penetrating injury
          • blood glucose needlestick
          • splinters
        • local spread
          • may spread from paronychia
        • no history of injury in 50% of patients
          • may result from bacterial contamination of the fat pad through the eccrine sweat glands
      • pathophysiology
        • overview
          • swelling and pressure within micro-compartments, leading to "compartment syndromes" of the pulp
        • progression
          • inflammation and cellulitis leads to local vascular congetsion
          • if left untreated, tissue necrosis and abscess formation leads to increased microvascular impairment
          • increasing pressure can eventually lead to "compartment syndrome" and subsequent ischemia
            • affects the blood supply to the diaphysis more than the blood supply to the skin, causing bone necrosis and sequestration before spontaneous decompression through the skin
      • organisms
        • Staphylococcus aureus
          • most common organism
        • gram negative organisms
          • found in immunosuppressed patients
        • Eikenella corrodens
          • found in diabetics who bite their nails
  • Anatomy
    • Fingertip pulp
      • closed sac connective tissue framework
      • separated by fibrous vertical septae running from periosteum of the distal phalanx to the epidermis
        • provides structural support
        • stabilizes the pulp during pinch and grasp
      • contains eccrine sweat glands that open onto the epidermis
    • Blood supply
      • digital arteries run parallel to the distal phalanx
        • gives off a nutrient branch to the epiphysis before entering the pulp space
  • Presentation
    • Symptoms
      • severe throbbing pain
    • Physical exam
      • swelling
        • does not extend proximal to DIP flexion crease unless flexor tendon sheath or joint is involved
      • tenderness
  • Imaging
    • Radiographs
      • indications
        • only indicated if history of trauma to rule out fracture or foreign body
    • MRI
      • indications
        • not indicated
  • Studies
    • Serum Labs
      • not indicated
  • Differential
    • Herpetic Whitlow
    • Paronychia
    • Glomus Tumor
    • Mucous cyst
    • Psoriasis 
  • Diagnosis
    • Clinical
      • diagnosis is made with careful history and physical examination
  • Treatment
    • Nonoperative
      • oral antibiotics and observation
        • indications
          • early felon (no drainable abscess)
    • Operative
      • bedside I&D and IV antibiotics
        • indications
          • most cases
  • Techniques
    • Bedside I&D
      • anesthesia
        • digital block
      • approach
        • keep incision distal to DIP crease
          • to prevent DIP flexion crease contracture and prevent extension into flexor sheath
        • mid-lateral approach
          • indicated for deep felons with no foreign body and no drainage
          • incision on ulnar side for digits 2-4 and radial side for thumb and digit 5 (non-pressure bearing side of digit)
        • volar longitudinal approach
          • most direct access
          • indicated for superficial felons, foreign body penetration, or visible drainage
        • incisions to avoid
          • fish-mouth incision
            • risk of unstable finger pulp or vascular compromise
          • double longitudinal or transverse incision
            • risk of injury to digital nerve and artery
      • debridement
        • avoid violating flexor sheath or DIP joint to prevent spread into these spaces
        • break up septa to decompress infection and prevent compartment syndrome of fingertip
        • obtain gram stain and culture
          • hold antibiotics until culture obtained
        • place gauze wick
      • postoperative
        • routine dressing changes
  • Complications
    • Finger tip compartment syndrome
    • Flexor tenosynovitis
    • Osteomyelitis
    • Digital tip necrosis
  • Prognosis
    • If left untreated, can lead to
      • sequestration of the diaphysis of the distal phalanx
      • pyogenic arthritis of the DIP joint
      • flexor tenosynovitis from proximal extension
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