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Internal Medicine

Felon

A felon is an abscess of the distal pulp or phalanx pad of the fingertip.

A felon is an abscess of the distal pulp or phalanx pad of the fingertip.

  • #2 M/C hand infection (25%)
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The fingertip pulp, compartmentalized by 15 to 20 fibrous septa running from the periosteum to the skin. The small compartments contain eccrine sweat glands and fat globules. The sweat glands provide a potential portal of entry for bacteria. An abscess in these noncompliant compartments is called a felon. | Clark, D. C. (2003) ‘Common acute hand infections.’, American family physician. United States, 68(11), pp. 2167–2176.

Aetiology

  • Penetrating trauma:
    • Splinters
    • Bits of glass
    • Abrasions
    • Minor puncture wounds
    • Multiple finger-stick blood tests
  • Untreated paronychia

Clinical features

  • Acute onset of severe throbbing pain with abscess formation on the palmar aspect of the fingertip

Complications

  • Tissue necrosis
  • Osteomyelitis
  • Pyogenic arthritis
  • Septicaemia

Management

Initial management:

  • Elevation
  • Oral antibiotics
  • Warm water or saline soaks

Incision and drainage

If fluctuance present
  • Complications:  Anesthetic fingertip, neuroma, and unstable finger pad

Amputation

If osteomyelitis present
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Felon drainage. The incision location should avoid injury to the flexor tendon sheath, digital neurovascular structures, and nail matrix. The incision is performed under digital anaesthesia, and a tourniquet may be applied to enhance visualization of the surgical field. Of two commonly used techniques, the volar longitudinal incision and the high lateral incision, the former is preferred. (A) The incision starts 3 to 5 mm from the distal interphalangeal (DIP) joint flexor crease and extends to the end of the distal phalanx. The depth of the incision is to the dermis. (B) The subcutaneous tissues are then gently dissected and explored with a small hemostat. Necrotic skin edges are excised, and the abscess is decompressed and irrigated. The high lateral incision is made on the nonoppositional side of the appropriate digit (ulnar side of the index, middle, and ring fingers, and radial aspect of the thumb and fifth digit). (C)The incision starts 5 mm distal to the flexor DIP crease and continues parallel to the lateral border of the nail plate, maintaining approximately 5 mm between the incision and the nail plate border. This distance should allow for avoiding the more volar neurovascular structures. (D)The incision is extended to end slightly distal to the unattached portion of the nail plate. The subcutaneous tissue is sharply dissected just volar to the volar cortex of the distal phalanx. The wound is bluntly dissected and explored, and the abscess is decompressed and irrigated. (E) In both techniques, the wound may be packed with sterile gauze. The gauze should be removed in approximately 24 to 48 hours, and the wound allowed to close by secondary intention. | Clark, D. C. (2003) ‘Common acute hand infections.’, American family physician. United States, 68(11), pp. 2167–2176.

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