Treatment of a Felon
A felon requires incision and drainage when an abscess has formed, with the preferred approach being a longitudinal incision in the volar space for superficial infections or lateral space for deep infections, combined with elevation, antibiotics, and careful attention to avoid extending the incision past the distal interphalangeal joint. 1
Initial Assessment and Early Management
Early-stage felons without frank abscess formation may be managed conservatively with:
- Oral antibiotics targeting common skin flora (Staphylococcus and Streptococcus species) 2
- Strict elevation of the extremity 2
- Removal of constricting jewelry or tight clothing 2
- Close monitoring for progression over 24-48 hours 1
However, once an abscess has developed, antibiotics alone are insufficient and surgical drainage becomes mandatory. 2, 1
Surgical Drainage Technique
The choice of incision depends on the depth and location of maximal tenderness:
Preferred Approaches
- Longitudinal volar incision: For superficial abscesses where the infection points volarly, this midline approach directly accesses the fat pad where most abscesses localize 1, 3
- Lateral incision: For deeper infections involving the pulp space, a unilateral longitudinal incision along the non-contact surface of the digit provides adequate drainage while preserving sensory function 1
Critical Technical Points
- Never extend the incision past the distal interphalangeal (DIP) joint to avoid iatrogenic flexor tendon sheath infection 1
- Drain the abscess where it points based on maximal tenderness 3
- Consider hockey stick or fish mouth incisions only in select cases with extensive involvement 1
Anatomical Considerations
Understanding the anatomy is essential to prevent complications:
- The distal pulp contains a complex system of fibrous septa that limit swelling and create a closed compartment 4
- When these septa are destroyed by infection, spread can occur into bone (osteomyelitis) or the flexor tendon sheath (tenosynovitis) 4
- This creates a digital compartment syndrome requiring urgent decompression 1
High-Risk Populations
Assess for conditions that alter treatment intensity and prognosis:
- Diabetes mellitus increases infection severity and delays healing 2
- Immunosuppressive states alter bacterial virulence and host response 2
- These patients require more aggressive initial treatment and closer follow-up 2
Complications of Inadequate Treatment
Delayed or improper treatment can result in:
- Palmar necrosis of the distal phalanx requiring reconstructive procedures such as groin flaps 5
- Flexor tendon sheath infection from proximal spread 5
- Osteomyelitis of the distal phalanx 4
- Permanent limitation of hand function 5
- Potential need for partial digital amputation 5
Post-Drainage Management
After surgical drainage:
- Continue oral antibiotics for 7-10 days targeting skin flora 2
- Maintain strict elevation 2
- Perform daily dressing changes with wound packing as needed 1
- Monitor for signs of proximal spread (flexor tendon sheath involvement) 5
- Ensure close follow-up within 24-48 hours to assess response 1
Common Pitfalls to Avoid
Critical errors that lead to poor outcomes:
- Relying on antibiotics alone once abscess formation has occurred 2
- Using inadequate incisions that fail to drain the entire abscess cavity 3
- Extending incisions beyond the DIP joint 1
- Failing to recognize immunocompromised states that require more aggressive management 2
- Delaying surgical intervention in established abscesses 5
"Minor" finger infections are only minor when diagnosed and treated properly; mistreatment can have long-term implications for both the individual and society. 2