Felon: Difference between revisions

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*Subcutaneous pyogenic infection of the pulp space compartments of the distal finger
*Subcutaneous pyogenic infection of the pulp space compartments of the distal finger
*Do not mistake for pulp erythema due to [[Paronychia|paronychia]] or [[Herpetic whitlow|herpetic whitlow]]
*Do not mistake for pulp erythema due to [[Paronychia|paronychia]] or [[Herpetic whitlow|herpetic whitlow]]
*Infection typically begins w/ minor trauma to dermis overlying finger pad (e.g. foreign body such as a splinter)
*Infection typically begins with minor trauma to dermis overlying finger pad (e.g. foreign body such as a splinter)
**May spread to flexor tendon sheath, IP joint, or underlying periosteum
**May spread to flexor tendon sheath, IP joint, or underlying periosteum
{{Fingertip anatomy}}


[[File:Felon 2.jpg|thumbnail|Felon]]
[[File:Felon 2.jpg|thumbnail|Felon]]
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==Clinical Features==
==Clinical Features==
*Red, tense, and markedly painful distal pulp space
*Red, tense, and markedly painful distal pulp space
**May see necrotic appearing tissue distally due to increased pressure in space


==Differential Diagnosis==
==Differential Diagnosis==
{{Template:Hand Infection DDX}}
{{Hand Infection DDX}}


==Diagnosis==
==Evaluation==
===Workup===
===Workup===
*X-ray to assess for foreign body
*X-ray to assess for foreign body
*[[Ultrasound]] can be utilized by placing the hand in a bowl of water and holding high frequency linear probe a few cm away from the finger (water is an excellent conductor)
*Gram stain and culture (chronic infections may be caused by atypical organisms)
*Gram stain and culture (chronic infections may be caused by atypical organisms)


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===Incision and drainage===
===Incision and drainage===
[[File:Felon.jpg|thumb|Incision of felon.]]
[[File:Felon.jpg|thumb|Incision of felon.]]
*Perform digital block
*The incision should be made along the''' ulnar aspect of the index, middle, and ring fingers''' and along the '''radial aspects of the thumb and little finger'''.  
*The incision should be made along the''' ulnar aspect of the index, middle, and ring fingers''' and along the '''radial aspects of the thumb and little finger'''.  
*Number 11 blade is used to make incision on nonoppositional side of affected digit
*Number 11 blade is used to make incision on nonoppositional side of affected digit.  Digital arteries and nerves arborize near the distal interphalengeal joint, minimizing risk of significant neurovascular damage.
*Start incision 5 mm distal to flexor DIP crease
*Start incision 5 mm distal to flexor DIP crease
*End incision 5mm proximal to nail plate border
*End incision 5mm proximal to nail plate border
*Bluntly dissect and explore wound until abscess is decompressed
*Bluntly dissect and explore wound until [[abscess]] is decompressed
''no need for packing''
''no need for packing''


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===[[Antibiotics]]===
===[[Antibiotics]]===
*Indicated for felon associated with cellulitis
'''Indicated for felon associated with cellulitis'''
{{Felon Antibiotics}}
{{Felon Antibiotics}}


==Disposition==
==Disposition==
*Discharge with followup in 2 days for wound check
*Discharge with follow-up in 2 days for wound check
*Refer to hand surgery only if systemically ill or concern for complicated infection  
*Refer to hand surgery only if systemically ill or concern for complicated infection  
*Instruct pt to keep extremity elevated
*Instruct patient to keep extremity elevated


==See Also==
==See Also==
*[[Hand and finger infections]]
*[[Hand and finger infections]]
*[https://www.youtube.com/watch?v=aGukN19fy7U Ultrasound Finger Exam Video]


==References==
==References==
<references/>
<references/>


[[Category:Derm]]
[[Category:Dermatology]]
[[Category:ID]]
[[Category:ID]]
[[Category:Ortho]]
[[Category:Orthopedics]]

Revision as of 20:25, 29 April 2020

Background

  • Subcutaneous pyogenic infection of the pulp space compartments of the distal finger
  • Do not mistake for pulp erythema due to paronychia or herpetic whitlow
  • Infection typically begins with minor trauma to dermis overlying finger pad (e.g. foreign body such as a splinter)
    • May spread to flexor tendon sheath, IP joint, or underlying periosteum

Nailtip Anatomy

A. Nail plate; B. lunula; C. root; D. sinus; E. matrix; F. nail bed; G. hyponychium; H. free margin.
  • The perinychium includes the nail, the nailbed, and the surrounding tissue.
  • The paronychia is the lateral nail folds
  • The hyponychium is the palmar surface skin distal to the nail.
  • The lunula is that white semi-moon shaped proximal portion of the nail.
  • The sterile matrix is deep to the nail, adheres to it and is distal to the lunule.
  • The germinal portion is proximal to the matrix and is responsible for nail growth.
Felon

Clinical Features

  • Red, tense, and markedly painful distal pulp space
    • May see necrotic appearing tissue distally due to increased pressure in space

Differential Diagnosis

Hand and finger infections

Look-Alikes

Evaluation

Workup

  • X-ray to assess for foreign body
  • Ultrasound can be utilized by placing the hand in a bowl of water and holding high frequency linear probe a few cm away from the finger (water is an excellent conductor)
  • Gram stain and culture (chronic infections may be caused by atypical organisms)

Evaluation

  • Usually a clinical diagnosis

Management

Incision and drainage

Incision of felon.
  • Perform digital block
  • The incision should be made along the ulnar aspect of the index, middle, and ring fingers and along the radial aspects of the thumb and little finger.
  • Number 11 blade is used to make incision on nonoppositional side of affected digit. Digital arteries and nerves arborize near the distal interphalengeal joint, minimizing risk of significant neurovascular damage.
  • Start incision 5 mm distal to flexor DIP crease
  • End incision 5mm proximal to nail plate border
  • Bluntly dissect and explore wound until abscess is decompressed

no need for packing

  • DO NOT perform a "fishmouth" incision since this may results in: Unstable finger pad, neuroma, and/or loss of sensation

Antibiotics

Indicated for felon associated with cellulitis Definitive treatment is drainage but antibiotic coverage for S. aureus and Strep with caution to identify Herpetic whitlow

Disposition

  • Discharge with follow-up in 2 days for wound check
  • Refer to hand surgery only if systemically ill or concern for complicated infection
  • Instruct patient to keep extremity elevated

See Also

References