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https://upload.orthobullets.com/topic/6102/images/10171_185felon[1]_moved.jpg
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https://upload.orthobullets.com/topic/6102/images/felon drainage surgical.jpg
Introduction
  • Overview
    • felon is a subcutaneous abscess of the fingertip pulp
      • treatment is usually I&D and IV antibiotics
  • Epidemiology
    • incidence
      • accounts for 15-20% of hand infections
    • location
      • most commonly occurs in the thumb or index finger
  • 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
  • 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
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
  • MRI
    • indications
      • not indicated
Studies
  • Serum Labs
    • not indicated
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
 

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