What is the treatment for a felon finger infection?

Treatment of Felon Finger Infection

Early aggressive surgical incision and drainage is the definitive treatment for established felon infections, with antibiotics serving as an adjunct rather than a replacement for surgical intervention. 1, 2, 3

Initial Assessment and Early Management

Immediate Measures

• Elevate the affected extremity and remove any constricting jewelry or tight clothing to reduce swelling and improve venous drainage 2
• Perform proper hand hygiene with antimicrobial soap and water or alcohol-based hand rub before examination 4
• Assess for high-risk features including immunocompromised status, diabetes, or other systemic diseases that alter infection severity 2

Clinical Examination

• Palpate for the characteristic tense, extremely painful swelling of the fingertip pulp space 5
• Probe carefully to assess depth and determine if infection has spread to bone (osteomyelitis) or flexor tendon sheath 6, 3
• Look for signs of compartment syndrome in the digital pulp space, which occurs due to the complex fibrous septa system that limits swelling 5

Treatment Algorithm

Early/Superficial Felons

Antibiotics alone may be attempted only in very early presentations without fluctuance or significant abscess formation 3

• First-line antibiotic: Amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days 4
• This approach requires close follow-up within 24-48 hours to ensure progression does not occur

Established Felons (Most Cases)

Surgical incision and drainage is mandatory and should never be replaced by antibiotics alone 2, 3

Surgical Approach Selection:

• For superficial felons: longitudinal incision in the volar (palmar) space 3
• For deep felons: lateral incision along the side of the digit to avoid neurovascular structures 3
• Critical: Do not extend the incision past the distal interphalangeal (DIP) joint to prevent iatrogenic flexor tendon sheath infection 3
• Hockey stick or fish mouth incisions may be required for extensive infections, though these carry higher morbidity 3

Post-Drainage Management:

• Irrigate thoroughly with sterile normal saline after drainage 4
• Cover with clean, dry bandage after any topical application 7
• Continue elevation and add adjunctive antibiotics (amoxicillin-clavulanate as above) 4, 1

Complications Requiring Extended Treatment

If Osteomyelitis Develops:

• Requires 4-6 weeks of antibiotic therapy 4
• May necessitate debridement of necrotic bone 6

If Septic Arthritis Develops:

• Requires 3-4 weeks of antibiotic therapy 4
• Surgical washout is typically indicated

If Flexor Tendon Sheath Infection Develops:

• This represents a surgical emergency requiring urgent drainage 6, 5
• Can result in palmar necrosis and may require reconstructive procedures including flap coverage 6

Critical Pitfalls to Avoid

• Never rely on antibiotics alone for established felons with fluctuance - this leads to progression and potential digit loss 2
• Never delay surgical drainage - the fibrous septa of the pulp space cause rapid pressure buildup and can lead to digital compartment syndrome 3, 5
• Never extend incisions proximal to the DIP joint unless there is documented flexor tendon sheath involvement 3
• Do not use topical bacitracin for established infections - it is only appropriate for minor cuts and scrapes, not deep infections 7

Expected Outcomes

With early aggressive surgical treatment combined with appropriate antibiotics, 76% of patients achieve good to very good results 1. However, delayed or inadequate treatment can result in significant long-term functional impairment, chronic pain, or even partial digit amputation 2, 6.