Felons

Definition

• A felon is a closed-space infection of the fingertip pulp, involving multiple small septated compartments within the pulp. Because the finger pad is divided by fibrous septa, infection and swelling can create significant pressure and pain, potentially leading to tissue necrosis if untreated.

Aetiology & Causes

• Usually arises from minor trauma (e.g. splinters, cuts, or penetrating injuries) that introduce bacteria into the pulp space.

• Can also spread from an adjacent infection such as paronychia (infection around the nail fold).

• Common pathogens: Staphylococcus aureus (including MRSA in some regions) and Streptococcus species.

Symptoms

• Early

  • Tightness, prickling or throbbing pain in the fingertip

  • Swelling, mild erythema

  • Pain may worsen with any pressure or use of the finger

• Late

  • Intense, pulsatile pain (due to increasing pressure within the tight compartments)

  • Erythema and visible swelling/abscess in the pulp

  • Difficulty using the affected hand/finger

Complications

• Abscess formation: If pressure builds up, subcutaneous pockets of pus can develop.

• Necrosis: Ongoing pressure and infection can compromise blood supply to the pulp.

• Permanent damage: If not relieved, it can lead to tendon or bone involvement (osteomyelitis of the distal phalanx).

Management

Early Intervention

• Empirical Antibiotics: Cover Staphylococcus aureus and Streptococcus (e.g. flucloxacillin or cephalexin).

  • If MRSA prevalence is high, consider trimethoprim-sulfamethoxazole or doxycycline (depending on local resistance patterns).

• Warm soaks and elevation: Can assist in early cellulitis without a defined abscess.

• Analgesia: NSAIDs or paracetamol to manage pain.

Incision & Drainage (I&D)

• If abscess or tension is present (throbbing, fluctuant swelling, severe pain), I&D is essential to decompress the pulp space.

• Technique: A small longitudinal incision on the volar pad, carefully avoiding neurovascular bundles.

• Aftercare: Saline washes, antibiotic dressings, and daily checks.

• Tetanus status: Ensure up-to-date vaccination if there was penetrating trauma.

Follow-Up

• Review in 24–48 hours to ensure resolution of infection and check for complications (e.g. osteomyelitis if pain localises to bone).

• Physiotherapy or hand therapy if stiffness or reduced function persists.

Notes

• Early recognition and prompt intervention reduce morbidity.

• Patient Education: Emphasise care with sharp objects, prompt disinfection of small cuts on fingers.

• Consider referral to hand surgery if complex, large abscess, or tendon involvement suspected.