Updated: 5/15/2021


Review Topic
https://upload.orthobullets.com/topic/6102/images/felon drainage surgical.jpg
  • 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
Flashcards (0)
1 of 0
Questions (2)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Evidence (5)
Private Note