Felon Treatment & Management

  • Author: Glen Vaughn, MD; Chief Editor: Steven C Dronen, MD, FAAEM   more...
 
Updated: Mar 29, 2012
 

Emergency Department Care

  • Adequate early treatment of a felon can prevent abscess formation.
  • As pain progresses, administer antibiotics with activity against staphylococcal and streptococcal organisms.
  • Decompress to preserve venous flow whenever tension is present, whether or not a frank abscess has formed.
  • Perform a digital block.
  • Perform a midline incision of the pad, because this is least likely to injure nerves or circulation.
  • Make short skin incision with a number 11 blade over the area of maximum tenderness. Incise only the skin with scalpel.
  • Evacuate pus using a blunt instrument in order to decrease the chance of severing the nerve or entering the tendon sheath. Do not divide vertical fascial strands (septa). For further information, see Hand, Paronychia Drainage.
  • Culture drainage if methicillin-resistant S aureus is prevalent.
  • Pack gauze loosely into the wound to prevent skin closure. Apply a loose dressing, splint the finger, and elevate the hand above the heart.
  • Update tetanus immunization.
  • Incisions
    • High lateral incisions, palmar longitudinal incisions, palmar transverse incisions, and hockey stick and fishmouth incisions have been recommended for drainage. Some of these incisions offer no benefit but increase the potential for serious injury. Drainage of puss is shown in the image below. Drainage of puss from under perionychium in a paroDrainage of puss from under perionychium in a paronychia.
    • The felon should be incised in the area of maximum tenderness. The incision should not cross the distal interphalangeal (DIP) joint to prevent formation of a flexion contracture at the DIP flexion crease. Probing is not carried out proximally to avoid extension of infection into the flexor tendon sheath.
    • A longitudinal incision in the midline is effective without serious iatrogenic complications that are observed with other traditionally recommended incisions.
    • Lateral or transverse incisions frequently cause ischemia and anesthesia by injuring one or both neurovascular bundles.
    • Fish-mouth incision can lead to an unstable painful fingertip.
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Consultations

  • Consult a hand surgeon for more complex cases.
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Contributor Information and Disclosures
Author

Glen Vaughn, MD  Director, Department of Emergency Medicine, Defiance Hospital

Disclosure: Nothing to disclose.

Specialty Editor Board

Jeffrey Glenn Bowman, MD, MS  Consulting Staff, Highfield MRI

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jon Mark Hirshon, MD, MPH  Associate Professor, Department of Emergency Medicine, University of Maryland School of Medicine

Jon Mark Hirshon, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Public Health Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM  Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. Connolly B, Johnstone F, Gerlinger T, Puttler E. Methicillin-resistant Staphylococcus aureus in a finger felon. J Hand Surg [Am]. Jan 2000;25(1):173-5. [Medline].

  2. Barkin JA, Miki RA, Mahmood Z, Landy DC, Owens P. Prevalence of methicillin resistant Staphylococcus aureus in upper extremity soft tissue infections at Jackson Memorial Hospital, Miami-Dade County, Florida. Iowa Orthop J. 2009;29:67-73. [Medline].

  3. Pallin DJ, Egan DJ, Pelletier AJ, Espinola JA, Hooper DC, Camargo CA Jr. Increased US emergency department visits for skin and soft tissue infections, and changes in antibiotic choices, during the emergence of community-associated methicillin-resistant Staphylococcus aureus. Ann Emerg Med. Mar 2008;51(3):291-8. [Medline].

  4. Newfield RS, Vargas I, Huma Z. Eikenella corrodens infections. Case report in two adolescent females with IDDM. Diabetes Care. Sep 1996;19(9):1011-3. [Medline].

  5. Glickel SZ. Hand infections in patients with acquired immunodeficiency syndrome. J Hand Surg [Am]. Sep 1988;13(5):770-5. [Medline].

  6. Bolton H, Fowler PJ, Jepson RP. Natural history and treatment of pulp space infection and osteomyelitis of the terminal phalanx. J Bone Joint Surg. 1949;4:499-504.

  7. Canales FL, Newmeyer WL, Kilgore ES. The treatment of felons and paronychias. Hand Clin. Nov 1989;5(4):515-23. [Medline].

  8. Clark DC. Common acute hand infections. Am Fam Physician. Dec 1 2003;68(11):2167-76. [Medline].

  9. Elston DM. Optimal antibacterial treatment of uncomplicated skin and skin structure infections: applying a novel treatment algorithm. J Drugs Dermatol. Nov-Dec 2005;4(6 Suppl):s15-9. [Medline].

  10. Hijjawi JB, Dennison DG. Acute felon as a complication of systemic paclitaxel therapy: case report and review of the literature. Hand (N Y). Sep 2007;2(3):101-3. [Medline].

  11. Kilgore ES Jr, Brown LG, Newmeyer WL. Treatment of felons. Am J Surg. Aug 1975;130(2):194-8. [Medline].

  12. Perry AW, Gottlieb LJ, Zachary LS, Krizek TJ. Fingerstick felons. Ann Plast Surg. Mar 1988;20(3):249-51. [Medline].

  13. Roberge RJ, Weinstein D, Thimons MM. Perionychial infections associated with sculptured nails. Am J Emerg Med. Oct 1999;17(6):581-2. [Medline].

  14. Watson PA, Jebson PJ. The natural history of the neglected felon. Iowa Orthop J. 1996;16:164-6. [Medline].

  15. Zyluk A, Puchalski P. [Severe infections within the upper extremity--analysis of the causes and methods of treatment]. Chir Narzadow Ruchu Ortop Pol. 2006;71(4):239-44. [Medline].

 
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Differential diagnosis for a felon includes herpetic whitlow.
A paronychia can progress to a felon if left untreated.
Drainage of puss from under perionychium in a paronychia.
 
 
 
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