Felon (whitlow)

FELON (WHITLO W) * JAMES Assistant

Professor of Surgery,

NORMAN

COOMBS,

TempIe University;

M.D.,

F.A.C.S.

Associate Surgeon, TempIe University

HospitaI

PHILADELPHIA ELON is a term appIied to infections invoIving the finger, and most commonIy affecting the dista1 phaIanx on the paImar surface. The infection may be superficiaI,l known as a subcuticuIar and subcutaneous feIon, or when deep is often caIIed a subperiostea1 bone felon. At times extension of infection by continuity or contiguity of tissue, especiaIIy in deep wounds or punctures, may Iead to synovia1 theca1 feIon (suppurative tenosynovitis). The mode of entrance of the infection may not aIways be cIear. Forgotten injuries or abrasions as we11as the dangerous punctured wounds are the common sources. Physicians and nurses frequentIy suffer from feIons, due either to needIe puncture while operating or in handIing sharp pointed instruments. Constitutional debiIity and obese types may offer suitabIe soi for bacteria1 invasion. The pecuIiar anatomy of the dista1 phaIanx as pointed out by KanaveI, Koch and others. is a factor in the IocaIized type of infection found in feIon. The connective tissue framework produces a cIosed sac with septa containing coIumns of fat and glands which extend to the periosteum (Fig. I). The bIood suppIy is received from the two digital arteries which enter IateraIIy and are encIosed in this fibroconnective tissue space. The epiphysis of the dista1 phaIanx receives its blood suppIy from branches of the digita arteries before the bIood vesseIs enter the cIosed space, the diaphysis receiving its bIood suppIy from branches given off in the cIosed space (Fig. 2). The resuIting pathoIogica1 process can readiIy be seen. When infection enters the finger, the inff ammatory exudate

F

1BABCOCK, W. W. Text Book deIphia, W. B. Saunders Co.

of Surgery,

* From the Department

PhiIa-

Iimited by the cIosed space and by the dense paImar skin, obstructs the bIood suppIy to this vuInerabIe area. EarIy abscess formation and necrosis of the diaphysis can be expected. SYMPTOMS

Pain is the most prominent symptom associated with redness and sweIIing. The pain in the beginning is usuaIIy sticking in nature, but soon changes to a severe puIsating type with marked tenderness. The finger tip by this time is buIbous and tense. If aIIowed to persist, Iymphangitis may occur with signs of systemic intoxication, increased puIse rate and temperature. ProximaI bone tenderness is not uncommon, often denoting periostitis or OsteomyeIitis. DIAGNOSIS

The diagnosis shouId be readiIy made by noting signs of inflammation confined to the termina1 phalanx, especially with In the differentia1 history of injury. diagnosis, Iymphangitis and tendon sheath infection shouId be eIiminated, particuIarIy in the earIy case. With these infections, sweIIing is usuaIIy diffuse, often invoIving the entire finger, most of the sweIIing being on the dorsa1 surface of the finger with ffexion deformity, particuIarIy in suppurative tenosynovitis. DiffIcuIty in the diagnosis may be experienced in the Iate case, when Iymphangitis of tenosynovitis has occurred from extension of the finger tip infection. PROGNOSIS

Great care and judgment should be exercised in the management of hand infec-

of Senior Surgery, Temple University, 366

PhiIadeIphia.

tions. As pointed out by Koch,2 there should be at Ieast one member of a hospital staff properly trained to treat minor surgi-

Di.a+ysis

Di$ital

no matter how triviaI, at the time of irljury with a protective dressing. With the onset of infection, absoIute rest

Epiphysti ?-

-xi

/ artery

FL&or tendon FIG. I. Longitudinal section of terminal phalanx of finger, semidiagrammatic. Anterior cIosed space, in which felon develops, corresponds to the portion of the pad which overlies the diaphysis of bone. The epiphysis and termination of the flexor tendon Iie outside this space. SmaII branches of the digital artery supplying the diaphysis pass through dense confines of the space and are quickly compressed by an inflammatory sweIIing. (Kanavel, A. B. and Mason, M. L. Hand Infections, CycIopedia of Medicine, Vol. vi. Phila., F. A. Davis Co., 1932.)

cal conditions, especiaIIy infections of the hand, where good functiona end resuIts are so important. Koch properly states that such infections are usuaIIy treated by the most inexperienced members of the staff. When treatment by free incision is carried out before bone necrosis ensues, early resoIution is to be expected. However, when OsteomyeIitis and bone necrosis occur, one must expect a discharging sinus unti1 sequestrum has been removed or discharged. The resuking deformity and dysfunction wiI1 depend upon the duration of suppuration and the amount of tissue destruction. TREATMENT

The prophyIactic treatment should precIude the steriIization ? KOCH, S. L. EditoriaI. 879 (April) 1939.

of feIon of wounds,

Surg. Cynec. and O&t., 60:

FIG. 2. Cross section of the terminal phalanx of the finger, semidiagrammatic. Dense fibrous coIumns (retinacuIa cutis) pass from the lower layer of the skin to attach to the periosteum. Between these columns is fatty tissue containing sweat glands, nerve fibers and bIood vessels. To obtain adequate drainage of the felon, it is necessary to divide these fibrous coIumns. (KanaveI, A. B. and Mason, M. L. Hand Infections, CycIopedia of Medicine, VoI. vi. Phila., F. A. Davis Co., 1932.)

shouId be provided by the use of abundant moist dressings. A saturated solution of boracic acid, two parts, and aIcoho1 70 per cent, one part, is an exceIIent soIution for such purpose. The dressings should incIude the entire hand and forearm. Provision should be made for introducing the soIution at reguIar intervaIs for constant moisture with suffkient outside covering to maintain heat. Dressings shouId be removed daiIy for inspection. CarefuI observation to determine the proper time for incision is important. One shouId not wait for fluctuation. On the other hand, one shouId not incise unti1 IocaIization has occurred in the dista1 phaIanx, and particuIarIy one shouId not incise during the period of earIy Iymphangitis. Incision during the earIy period of Iymphangitis wiI1 be of no value and in many instances causes widespread dissemination of the infection aIong the Iymph vesseIs of the hand, forebIood stream arm, arm and at times invasion.

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American Journal of Surgery

Kanave13 points out that the incision shouId be made as soon as the edema restricted to the distaI phaIanx has pro-ine

of intiision

0 i-_ -_______*

0 2

Point

t

1

of incision

FIG. 3. Proper

incision for drainage of felon. It is unnecessary and unwise to carry the incision across the tip of the finger. The essentia1 feature of drainage is the transverse division of the retinacuIa of the skin. (From Koch. J. A. M. A., April 6, 1929.) (Kanavel, A. B. and Mason, M. L. Hand Infections, Cyclopedia of Medicine, Vol. vi. PhiIa., F. A. Davis Co., 1932.)

ceeded to a degree causing a hardness, but not necessariIy the board-Iike feeIing char-

phalanx with excessive edema Iimited to the phalanx, incision shouId be made. The Anesthetic. The use of a genera1 anesthetic4 wiI1 aIIow the surgeon ample time to make an adequate incision to insure the best resuIt. If IocaI anesthesia is used, the digital nerves shouId be bIocked at the base of the finger. The use of a IocaI anesthetic or ethy1 chIoride in the zone of inffammation favors diffusion of the infection and inadequate incision. Metbod of Incision. NaturaIIy, the incision shouId be made over the area of greatest tenderness, particuIarIy so if the case is seen earIy enough to decide that the cIosed space of the dista1 phaIanx is partiaIIy invoIved. However, if it is reaIized that the entire dista1 phaIanx is affected, the method of Koch may be used (Fig. 3). The incision should be pIaced to the side of the finger to preserve deIicate tactiIe sensation, otherwise disturbed by a median incision. The knife is introduced on an oblique pIane extending we11 to the opposite side of the finger, making a free incision with division of the coIumns of connective tissue and fat, thus Iiberating any associated discrete pockets of pus. In one’s eagerness to make a free incision, the knife shouId not extend beyond the base of the phaIanx; eIse, the

FIG. 4. Deformity of terminal phaIanx of thumb resulting from feIon, improved by liberation of the scar and implantation of fat. (KanaveI, A. B. Infections of the Hand. PhiIa., Lea & Febiger.)

acteristic of pus in other subcutaneous areas. In generaI, one may say that when there is present a painful, tender, dista1 s KANAVEL, A. B. Infections of the Hand. PhiIadelphia, Lea and Febiger, 162.

Ed.

6.

flexor tendon sheath wiI1 be contaminated, favoring a tenosynovitis. Vaseline gauze drains are suggested as rubber tubing may cause pressure necrosis4 KOCH, S. L. J. A. M. A., 92:

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Excessive packing should be avoided; a thin strip of gauze introduced to the depth of the wound is ample. EarIy remova of the drain is suggested. In the immediate postoperative treatment, abundant moist dressings shouId be apptied to in&de the entire hand, as before described, during the period of IocaIization, with rest in bed. For ambuiant treatment, a splint extending from the finger tip to the eIbow, with the use of a sIing is to be considered for appropriate rest and immobiIization to favor resolution. Results. When incision has been deIayed and mass destruction of soft tissue and bone has occurred, prolonged drainage is to be expected. In the case of necrosis of the diaphysis, drainage wiI1 continue untiI sequestrum has been discharged or removed. The removal of sequestrum may be faciIitated by instrumentation, after partia1 separation has taken place. At no time shouId a curette be used on account of injury to or remova of periosteum, thus interfering with bone regeneration and

American Journal of Surgcrt

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function. Amputation should not be considered unless there has been compIete destruction of the termina1 phaIangea1 joint. In the average uncompIicated felon, a good functiona resuIt is usuaIIy obtained. PIastic operations for correction of the deformity may be necessary (Fig. 4). Contracted scars of the finger tip may be Iiberated with impIantation of fat, to improve function. SUMMARY

The articIe deals with the cause and varieties of felon, together with a description of the anatomy and pathoIogy. The symptoms, diagnosis and differential diagnosis are discussed incIuding the management and prognosis of finger tip infections. The treatment incIudes methods aiding IocaIization, types of incisions and drains to be used, aIso the care of osteomyelitis and bone necrosis. Four iIIustrations are used to expIain the text of the article.