Cellulitis With Felon

For 3 days, a 47-year-old woman had a painful red swelling on her finger. The patient—a cellist—had tried to lance the lesion at home, but it progressively worsened and was now “throbbing.” She denied fever and nail biting. The patient was in moderate distress; temperature was 36.8°C (98.3°F); blood pressure, 123/80 mm Hg; and heart rate, 62 beats per minute. She had no thrush, murmur, lymphangitis, or lymphadenitis. The entire distal portion of the fifth finger of her left hand was swollen.

There was a small pointed abscess on the ulnar aspect of the finger that appeared more extensive than a paronychia. The swollen and slightly tender finger pad was neither fluctuant nor tense. Radiographs showed no bony involvement. Brady Pregerson, MD, of Los Angeles, anesthetized the finger with ethylene oxide and lanced the abscess. A small amount of pus was expressed. Because Dr Pregerson suspected a felon, he consulted a hand surgeon, who ultimately diagnosed cellulitis of the fingertip with early felon formation. The specialist performed a more extensive incision and drainage but did not incise the finger pad. A No. 15 blade was used to continue the original incision down to the level of the distal phalanx. Immediate egress of purulent material was noted.

Cultures of the purulent material were strongly positive for Staphylococcus aureus; the strain was not methicillin-resistant. An approximate 1-cm incision was created radially and laterally. Distal tissue was excised to ensure complete removal of the roof of the abscess cavity. The wound was copiously irrigated with sterile normal saline, packed with iodoform gauze, and dressed with an antimicrobial bandage. A volar (or wrist cock-up) splint was applied, and the hand was elevated with a pillow. Therapy with intravenous piperacillin/tazobactam was started, and the patient was hospitalized for observation. After 2 days, the patient was discharged with instructions to change the dressing twice daily.

She was advised to soak the affected digit in half-strength hydrogen peroxide mixed with sterile normal saline for 20 minutes before repacking the wound and replacing the splint. She continued this regimen with elevation and oral amoxicillin/clavulanate, 875 mg bid, for 10 days. A week after the splint was removed, the patient began to play the cello again. The finger remained sensitive for about a month; no long-term sequelae were reported.