Treatment of a Felon
The definitive treatment for a felon (pulp space infection of the fingertip) is prompt surgical incision and drainage without the need for postoperative antibiotics in uncomplicated cases and immunocompetent patients. 1
Definition and Anatomy
A felon is an abscess of the distal pulp of the fingertip that occurs in the closed space of the distal fat pad. Understanding the anatomy is crucial for proper treatment:
- The fingertip pulp is divided into multiple small compartments by fibrous septa
- These compartments limit the spread of infection but also create high pressure when infected
- Without proper drainage, the infection can spread to the flexor tendon sheath, bone, or joint
Diagnosis
- Severe throbbing pain in the fingertip
- Tense, erythematous swelling of the pulp
- Tenderness to palpation
- The fingertip may appear dusky if treatment is delayed
- Point of maximal tenderness helps determine the optimal incision location
Treatment Algorithm
1. Surgical Management (Primary Treatment)
- Incision and drainage is the definitive treatment 2, 1
- Preferred incision: midvolar longitudinal incision where the abscess points 2
- Alternative incisions only if maximal tenderness is elsewhere
- Complete drainage of all loculations is essential to prevent recurrence
- Avoid "hockey stick" or "fish-mouth" incisions that can damage neurovascular structures
2. Antibiotic Therapy
- Antibiotics are NOT necessary after adequate surgical drainage in uncomplicated cases 1
- A prospective study of 46 patients showed excellent results (45/46 cases healed without complications) with surgical excision alone 1
- Reserve antibiotics for:
- Immunocompromised patients
- Diabetics
- Patients with cardiac valve prostheses
- Cases with signs of:
- Osteomyelitis
- Flexor tenosynovitis
- Lymphangitis
- Septic arthritis
3. Post-Procedure Care
- Elevation of the affected hand
- Daily dressing changes
- Follow-up within 24-48 hours to assess healing
- Additional follow-up at 7,14, and 21 days to ensure complete resolution
Complications
Delayed or inadequate treatment can lead to:
- Flexor tenosynovitis
- Osteomyelitis of the distal phalanx
- Septic arthritis of the DIP joint
- Necrosis of the pulp requiring reconstructive procedures 3
- Permanent functional impairment
Special Considerations
- Atypical infections: Consider mycobacterial infections (e.g., Mycobacterium abscessus) in cases with poor response to standard treatment, especially with history of nail salon exposure 4
- For mycobacterial infections, prolonged antibiotic therapy with multiple agents may be required 4
Key Points
- Early recognition and proper surgical drainage are essential
- The single most important factor in successful treatment is complete surgical drainage
- Antibiotics alone without drainage will not resolve a felon
- "Minor" finger infections can have major consequences if not treated properly 5
- Prevention through proper hand hygiene and avoiding trauma to the fingertips is important