Case Challenge: A Diabetic Woman With Left Index Finger Pain

Stephen L. Viviano, MD; Mark S. Granick, MD


July 28, 2016

Approach to an Acute Felon

A felon is a closed-space infection involving the volar pulp of the fingertip. Kanavel[1] described the pulp as a distinct compartment formed by fibrous separations between the distal phalanx and the volar skin. The clinical signs of infection begin with pain, swelling, and erythema localized to the distal pulp. As the infection progresses, the pressure inside the compartment increases, leading to ischemia and tissue necrosis of the pulp. The remainder of the finger is classically spared. However, untreated or neglected felons can progress beyond the pulp to cause skin necrosis, osteomyelitis, septic arthritis, and tenosynovitis.[2]

Acute felons without evidence of abscess formation can be treated with empiric oral antibiotics with MRSA coverage, with or without the addition of warm soaks. If a frank abscess forms, prompt incision and drainage is recommended.[3] The drainage is performed using one of two commonly used incisions. The classic incision is a midaxial "hockey stick" incision made on the noncontact side of the finger (ie, the radial side of the thumb or the ulnar side of the fingers). The incision is carried down to the periosteum and followed by blunt dissection through the fibrous septae to ensure complete drainage of the compartment. A central longitudinal incision can also be made from the pulp apex to the DIP joint flexion crease.[4] This incision typically heals well and spares the neurovascular bundles. As a result, the incision may be less painful.

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