At the Bedside

  • History: fingertip pain, throbbing, swelling, penetrating trauma, splinter, nail biting, diabetes/immunocompromise.
  • Exam:
  • Tense, swollen, exquisitely tender finger pad distal to DIP.
  • Usually spares the nail fold unless associated paronychia.
  • Assess:
  • Capillary refill and sensation.
  • Passive ROM of DIP/PIP.
  • Kanavel signs to exclude flexor tenosynovitis.
  • Paronychia, herpetic whitlow, foreign body, open wound.
  • Workup:
  • Usually clinical.
  • X-ray if trauma, foreign body concern, recurrent infection, severe swelling, or concern for distal phalanx osteomyelitis.
  • Ultrasound can identify abscess vs cellulitis if unclear.
  • Initial management:
  • Digital nerve block.
  • Remove rings.
  • Tetanus update.
  • If early cellulitis without fluctuance/tension: warm soaks, elevation, oral antibiotics, close follow-up.
  • If abscess/tension: I&D required.
  • I&D technique:
  • Use digital block; avoid injecting directly into infected pulp.
  • Prep widely; finger tourniquet can help visualization but remove promptly.
  • Incision options:
  • Unilateral longitudinal incision over area of maximal fluctuance, usually lateral/volar-lateral pulp.
  • Avoid midline volar incision over sensory pad.
  • Avoid transverse “fish-mouth” incision due to painful scar/instability risk.
  • Avoid crossing DIP crease.
  • Bluntly break septations with hemostat.
  • Irrigate.
  • Consider small wick/packing for 24–48 hr if large cavity; do not overpack.
  • Splint in position of function, elevate.
  • Antibiotics:
  • Cover Staph aureus and Strep; add MRSA coverage if risk factors or purulence.
  • Antibiotics are commonly used after felon drainage due to closed-space infection, especially if cellulitis, immunocompromise, severe infection, or delayed presentation.
  • Disposition:
  • Outpatient if uncomplicated and drained well; recheck in 24–48 hr.
  • Hand surgery consult/admit if:
  • Flexor tenosynovitis concern.
  • Osteomyelitis.
  • Necrosis.
  • Immunocompromised/septic.
  • Failed outpatient therapy.
  • Extensive tissue destruction or neurovascular compromise.
A Classic Presentation
A 42-year-old mechanic presents with 3 days of worsening throbbing pain in the distal index finger after a metal splinter. Exam shows tense swelling and severe tenderness of the volar fingertip pad without pain along the flexor sheath. X-ray shows no foreign body or bony involvement. After digital block, a lateral longitudinal incision releases purulence; septations are bluntly broken, the wound is irrigated, a small wick is placed, and he is discharged with MRSA-active antibiotics and 24–48 hr recheck.

Study Directive

  • Draw fingertip pulp anatomy and label where a safe felon incision goes.
  • Practice verbalizing the difference between felon, paronychia, herpetic whitlow, and flexor tenosynovitis.
  • Review hand infection disposition criteria and create a 24–48 hr follow-up script.
  • Watch one procedural video on felon I&D and mentally rehearse digital block → incision → blunt dissection → irrigation → dressing.

Recent Literature