Updated: 11/29/2018

Felon

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Introduction
  • Infection of finger tip pulp
    • usually thumb and index finger
  • Pathophysiology
    • mechanism
      • penetrating injury including
        • blood glucose needle stick 
        • splinters
      • local spread
        • may spread from paronychia 
      • no history of injury in 50% of patients
    • pathoanatomy
      • swelling and pressure within micro-compartments, leading to "compartment syndromes" of the pulp
    • organism
      • Staphylococcus aureus
        • most common organism
      • gram negative organisms
        • found in immunosuppressed patients
      • Eikenella corrodens
        • found in diabetics who bite their nails
Anatomy
  • Fingertip micro-compartments
    • pulp fat is separated by fibrous vertical septae running from distal phalanx bone to dermis
Presentation
  • Symptoms
    • pain, swelling  
  • Physical exam
    • tenderness on distal finger
Treatment
  • Operative
    • I&D in emergency room followed by IV antibiotics
      • indications
        • most cases due to risk of finger tip compartment syndrome
Techniques
  • Fingertip irrigation & debridement 
    • 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 not discharging
        • incision on ulnar side for digits 2,3 and 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  
        • fishmouth incisions - leads to unstable finger pulp
        • double longitudinal or transverse incision - injury to digital nerve and artery
    • debridement
      • avoid violating flexor sheath or DIP joint to avoid 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
    • postoperative
      • routine dressing changes
Complications
  • Finger tip compartment syndrome
  • Flexor tenosynovitis
  • Osteomyelitis
  • Digital tip necrosis
 

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