What is the role of incision in the emergency department (ED) care of patients with felon?

Updated: Mar 11, 2021
  • Author: Brandon Stein, MD; Chief Editor: Steven C Dronen, MD, FAAEM  more...
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Multiple incisions have been proposed for the incision and drainage of a felon, however no randomized trials exist. Most experts recommend either a unilateral longitudinal approach, a volar approach or a hockey stick appropach. [4]

All attempts should be made for the incision to be in the area of maximum swelling and tenderness. The incision should not cross the distal interphalangeal (DIP) joint to prevent formation of a flexion contracture at the DIP flexion crease. Probing is not carried out proximally to avoid extension of infection into the flexor tendon sheath.

A longitudinal incision in the midline is effective without serious iatrogenic complications that are observed with other traditionally recommended incisions. Incisions should ideally made on the opposite side of the pinching surface unless the point of maximal fluctuance is on the pinching surface. The incision should be made on the ulnar side of digits 2,3,4 and the radial side of digits 1 and 5. 

When using the longitudinal approach, it should begin doral to and 0.5cm distal to the DIP flexion crease and extend distally. Care should be made not to violate the tendon sheath. The wound should be deepend along a plane until the abscess is entered. Using tenotomy scissors or a hemostat care should be made to break up all involved septa. [13]

 A wik may be placed in the incision to allow continued drainage for 2-5 days.  [14]

Daily soaks in warm soapy water or dilute povidone-iodine solution can be used.

Other approaches not discussed are associated with a variety of complications.

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