Felon Treatment & Management

Updated: Nov 19, 2018
  • Author: Jarod Fox, MD; Chief Editor: Steven C Dronen, MD, FAAEM  more...
  • Print
Treatment

Emergency Department Care

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

Administer antibiotics with activity against methicillin-resistant Staphylococcus.

Decompression is essential to preserve blood flow, whether or not a frank abscess has formed.

A digital block provides adequate local anesthesia.

Incisions near the midline of the pad are least likely to injure nerves or blood vessels.

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.

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.

Next:

Consultations

An orthopedist or hand surgeon should be consulted for more complex cases, especially when there is concern for osteomyelitis or flexor tenosynovitis.

Because of the potential for complications, prompt follow-up should be arranged in all cases. Surgical consultation should be obtained if there is no improvement within 12-24 hours of conventional therapy.

Previous
Next:

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 for MRSA is recommended. Gram stain, if available, should be used to guide therapy.

Provide tetanus prophylaxis if appropriate.

Previous
Next:

Surgical Care

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

Previous
Next:

Complications

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

Previous