What is the treatment for pulp infections of the fingers?

Treatment of Fingertip Pulp Infections (Felons)

Surgical incision and drainage is mandatory for established felons, combined with oral antibiotics, splinting, and elevation; early felons may respond to antibiotics and warm soaks alone, but any fluctuance or significant pain requires immediate surgical drainage to prevent complications including osteomyelitis and permanent disability. 1

Initial Assessment and Early Intervention

• Early-stage felons (within 24-48 hours, minimal fluctuance, no severe pain) may be treated conservatively with elevation, oral antibiotics, and warm water or saline soaks 1
• However, most felons present beyond this early window and require surgical treatment 2
• The key distinguishing feature is whether fluctuance (pus collection) is present on examination 1

Surgical Management - The Definitive Treatment

• Incision and drainage is required for any felon with fluctuance, severe pain, or failure to improve with 24-48 hours of conservative management 1, 2
• The subcutaneous abscess of the distal pulp must be surgically drained to prevent spread to bone, joint, or tendon structures 1
• Surgical treatment should not be delayed, as felons can rapidly progress to osteomyelitis if inadequately treated 2

Antibiotic Therapy

• Oral antibiotics should be initiated in conjunction with surgical drainage 1, 2
• For typical felons without specific risk factors, coverage should target aerobic gram-positive cocci (Staphylococcus and Streptococcus species) 1
• Duration is typically 7-10 days for uncomplicated infections 3
• If there is concern for deeper involvement (bone, joint), longer courses may be necessary 3

Adjunctive Measures

• Splinting of the affected digit helps reduce pain and promotes healing 1
• Elevation of the hand above heart level reduces swelling and accelerates resolution 1
• Warm water or saline soaks 3-4 times daily after drainage facilitate continued drainage and healing 1, 2

Tetanus Prophylaxis

• Administer tetanus toxoid booster if more than 5 years since last dose, as these are considered contaminated wounds 4

Critical Pitfalls to Avoid

• Do not confuse herpetic whitlow with a felon - herpetic whitlow is caused by herpes simplex virus and surgical drainage is strongly contraindicated as it can worsen the condition and spread infection 1, 2
• Herpetic whitlow appears similar but has vesicular lesions and is self-limited over 3-4 weeks 2
• Do not delay surgical drainage once fluctuance is present - conservative management beyond 48 hours risks progression to osteomyelitis 1, 2

Follow-up and Monitoring

• Reassess within 24-48 hours to ensure clinical improvement 1
• If erythema and drainage persist despite proper treatment, obtain radiographs to rule out osteomyelitis 2
• Osteomyelitis requires 4-6 weeks of antibiotic therapy if it develops 4