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Felon Treatment & Management

  • Author: Jarod Fox, MD; Chief Editor: Steven C Dronen, MD, FAAEM  more...
 
Updated: Feb 29, 2016
 

Emergency Department Care

Adequate early treatment of a felon can prevent abscess formation and other serious complications.

Administer antibiotics with activity against staphylococcal and streptococcal organisms.

Decompression is essential 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 a short skin incision with a number 11 blade over the area of maximum swelling and tenderness. Incise only the skin.

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 any drainage.

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 in the past. Some of these incisions offer no benefit but increase the potential for serious injury. Drainage of pus is shown in the image below.

Drainage of pus from under perionychium in a paron Drainage of pus from under perionychium in a paronychia.

The felon should be incised in the area of maximum swelling and 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 (eg, upon concern for osteomyelitis or flexor tenosynovitis). Because of the potential for complications, prompt follow-up should be arranged in all cases. Consultation should be obtained if there is no improvement within 12-24 hours of conventional therapy.

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Medical Care

If treated early, drainage, elevation, and oral antibiotics may be adequate. Appropriate follow-up should always be arranged. Severe infections and complicated cases may require hospitalization for intravenous antibiotics and surgical drainage.

The most common organism involved is S aureus, accounting for around 80% of cases. Empiric coverage with a first-generation cephalosporin or antistaphylococcal penicillin is usually adequate in uncomplicated infections. Gram stain, if available, should be used to guide therapy.

Provide tetanus prophylaxis if appropriate.

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Surgical Care

If drainage and antibiotic therapy yield no improvement within 12-24 hours, consultation with a surgeon is recommended.

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Complications

Potential complications of felon include fingertip necrosis, osteomyelitis, and/or flexor tenosynovitis.

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Contributor Information and Disclosures
Author

Jarod Fox, MD Fellow in Infectious Diseases, Orlando Health

Jarod Fox, MD is a member of the following medical societies: American College of Physicians, International Society for Infectious Diseases

Disclosure: Nothing to disclose.

Coauthor(s)

Mary Catherine Bowman, MD, PhD Program Director, Infectious Diseases Fellowship Program, Orlando Health

Mary Catherine Bowman, MD, PhD is a member of the following medical societies: American College of Physicians, American Medical Association, Infectious Diseases Society of America, Florida Infectious Diseases Society

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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

Jon Mark Hirshon, MD, MPH, PhD 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, 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, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

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

Disclosure: Nothing to disclose.

Acknowledgements

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

Disclosure: Nothing to disclose.

References
  1. Franko OI, Abrams RA. Hand infections. Orthop Clin North Am. 2013 Oct. 44(4):625-34. [Medline].

  2. 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].

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

  4. 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]. [Full Text].

  5. 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. 2008 Mar. 51(3):291-8. [Medline].

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

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

  8. 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.

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

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

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

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

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

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

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

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

  17. 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].

  18. Anthony Barabas, Andrew Fleming. Hand Infections. I.A. Trail, A.N.M. Fleming. Disorders of the Hand. London: Springer-Verlag; 2015. 1: 415-417.

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