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 | *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== | ||
{{ | {{Hand Infection DDX}} | ||
== | ==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''' | |||
{{Felon Antibiotics}} | {{Felon Antibiotics}} | ||
==Disposition== | ==Disposition== | ||
*Discharge with | *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 | *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: | [[Category:Dermatology]] | ||
[[Category:ID]] | [[Category:ID]] | ||
[[Category: | [[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
- 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.
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
- Bed bugs
- Closed fist infection (Fight Bite)
- Hand cellulitis
- Hand deep space infection
- Hand-foot-and-mouth disease
- Herpetic whitlow
- Felon
- Flexor tenosynovitis
- Paronychia
- Scabies
- Sporotrichosis
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
- 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
- Cephalexin 500mg PO q6hrs daily x 7 days
- TMP/SMX 2 DS tablets PO q12hrs x 7 days
- Clindamycin 450mg PO q8hrs x 7 days
- Dicloxacillin 250mg PO q6hrs daily x 7 days
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