What is a Felon and what should we do about it?
Check out the papers and pages mentioned.
Nardi NM, McDonald EJ, Syed HA, et al. Felon. [Updated 2024 Apr 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430933/
Orthobullets page by Leah Ahn MD
Koshy JC, Bell B. Hand Infections. J Hand Surg Am. 2019 Jan;44(1):46-54. doi: 10.1016/j.jhsa.2018.05.027. Epub 2018 Jul 14. PMID: 30017648.
Clark DC. Common acute hand infections. Am Fam Physician. 2003 Dec 1;68(11):2167-76. PMID: 14677662. https://pubmed.ncbi.nlm.nih.gov/14677662/
Tannan SC, Deal DN. Diagnosis and management of the acute felon: evidence-based review. J Hand Surg Am. 2012 Dec;37(12):2603-4. doi: 10.1016/j.jhsa.2012.08.002. PMID: 23174075.
Proegler C. The Panaritium (Felon)-Consequences and Treatment. Chic Med J. 1872 Nov;29(11):656-660. PMID: 37413177; PMCID: PMC9802920. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9802920/
Billroth T. Panaritium. Atlanta Med Surg J (1884). 1884 Mar;1(1):35-37. PMID: 35827592; PMCID: PMC8925372. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8925372/
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Does this condition have a criminal record? Hello and welcome to this week's urgent bite brought to you by the Royal New Zealand College of Urgent Care. My name is Guy Melrose and today we take a quick look at felons. There are many considerations you will make in determining the disposal and management of your patient in urgent care. Those that obviously need hospital and those that can be discharged home following treatment are at either end of a spectrum. And these are quite straightforward to determine. But there are cases in the middle that are not always obvious and many clinical, logistical, practical, financial, personal, and patient-focused factors might play into your decisions about whether or not a patient requires hospital management or not. These are hard decisions. But I think there are a couple of factors that often come into play that can add to this difficulty and are particularly challenging for more junior staff. And that is an expectation from either the hospital team or the patient that you can manage something within your clinic. And also the personal pressure applied by oneself to be what in your eyes is a competent and effective practitioner. These two things might lead to a decision to undertake a procedure or a treatment, and when added to the ongoing pressure from hospitals to prevent referrals and the long waits in many hospitals at the moment, we in urgent care can sometimes feel obligated to do more than we might want. Now this is something we could talk about for a long time, but I've been reflecting on this concept this week in light of a case of felon that I had. And I think this is an interesting frame to put around the case and to consider when looking at the management. So my reading around the topic of felon has been informed mainly by the ortho bullets page by Lea Arn, the stat pearls page by Nadi et al, and a paper from the Journal of Hand Surgery, America from 2019 called Hand Infections by John Koshy and Bryce Bell. All these references are linked in the show notes. So a felon is an infection of the fingertip pulp. They account for about 20% of hand infections and can be caused by direct trauma, so garden splinters and glucometers being the most common causes. Or from spread from another infection, usually a paranichia. But 50% have no history of trauma at all. They present with rapid onset pain and swelling to the fingertip pulp. It is a severe, throbbing pain and the fingertip is swollen and tense. The patient will not be very happy. Now it is in the fingertip anatomy that is the reason these patients present this way and also one of the reasons for the complications. The fingertip has fibrous vertical septae that run from the periosteum of the distal phalanx all the way to the epidermis. This is a structure that provides good stability for the fingertip and aids in our pinch and touch, but it does create a series of compartments anchored to the periosteum. And so as infection develops and passes formed, multiple little areas of compartment syndrome are created. So as with compartment syndrome anywhere else, the increasing pressure causes pain, but also compromised blood supply. So necrosis is a real risk. Also, due to the attachment to the periosteum, the diaphacyal blood supply can also be disrupted, so bone necrosis can occur. So it is important to identify a phalan and drain the pus quickly to prevent these and other complications, which include osteomyelitis and flexatinous side ofitis. So to identify this in urgent care, a patient with severe finger or thumb tip pain that is throbbing and has a tense and tender distal phalanx pulp that is contained distal to the distal interphalangeal joint is likely to have a phalan. Parentic years, while perhaps present in the preceding days, are infections around the nail fold. A hepatic wit-low is another differential to consider, but should be easy to differentiate by the presence of vesicles. In 2012, Tannen et al. wrote a review titled Diagnosis and Management of the Acute Felon Evidence-based Review in the Journal of Hand Surgery, and they found only articles with expert-level opinion. But their conclusions were that early felons, those without abscess formation, so still in the cellulitis phase, can be managed with oral antibiotics, but if there's any pus collection, then that needs to be incised and drained. Stat pearls and orthobolites also agree with this. Staff aureus is the most common organism to cover, so if we see an early pulp infection, without pus, start oral antibiotics, rest and elevate the hand, and arrange close review and safety netting. But due to the complications and the severe pain associated with a felon, if pus is present, this needs to be incised and drained, which is where my reflections at the start of this podcast come back to the fore. Incision and drainage is done under a simple ring block. There are various descriptions out there, but it is important to use the right approach and the right incision type. And due to the septate nature of the compartments, it is difficult to drain all the pus, so these need to be broken up and the area needs debriding. Necrotic tissue needs to be removed, care needs to be taken to avoid the flexor sheath. Complications of the procedure include neuroma formation, an anesthetic fingertip, and an unstable finger pad. Once fully debrided, the finger needs to get packed and splintered and dressings are needing to be followed on through. Now, this might sound like something we can do in urgent care. We have all the equipment, and even ortho bullets describe it as a bedside technique. We insize and drain abscessors in some places, and within certain limitations, elsewhere in the body. So, does that mean that we can do it in urgent care? Well, for me, the answer is no. Not least because to do this properly takes time, and our clinics are too busy to be devoting this time to this procedure for one patient. But I think the felon is more complicated than an abscess of, say, someone's buttock. It requires more complicated debriding and breaking up of the scepter. It involves avoiding nerves and tendon sheaths. It involves identifying necrotic tissue and dealing with it. It requires the right incision in the right place, and all these things make me realise that my practice of referring for a hand surgeon to perform this is the right thing. At least, for me. Now, there may be some of you who have surgical training, or surgical skills, and have maintained these such that you are comfortable in doing this procedure. But for those of you, like me, we should not feel pressured into draining a felon. It is not a simple abscess, and a finger or thumb is too important a structure to mess around with. Our job, the expectation of an urgent care clinician, should be to identify, treat early ones with antibiotics before pus has collected, and refer those with pus to a surgeon to drain. Well, dating back to 2003, a paper in the American Family Physician by Duane Clark called "common hand infections" summed up the felon nicely for me, and I quote directly, "The family physician's comfort level and the availability of a surgeon may determine whether this procedure is performed in the family physician's office, or if the patient is referred." Now, you might be interested in why it is called a felon. While you might associate a felon with a criminal, from what I can gather, the name comes from Latin via French and relates to the French word for bile. So it is a bile-filled collection of nastiness in the finger, even though it's not actually bile. I think a criminal felon was also thought to be evil and full of bile, so there is probably an etymological connection there, too. It is an ancient condition, though. I have found scans of the Atlanta and Chicago medical journals from the late 1800s that talk about felons, and while the language is older, and more formal, they still advocated for early incision back then, but to do so with the patient fully narcosed. Of interest, an older word for the condition before felon was used seems to be panoritium. Now, I'll link to these articles in the show notes for those of you who are interested in old medical texts, but my take home is identify a felon as early as possible as a severely painful, throbbing finger or thumb tip, and if evidence of pus, unless you're trained and have the skills and time to do so, refer for a surgeon to in size and drain, so as to prevent ischemic damage, osteomyelitis, flex attendant infection, and ongoing distress. And for those of you who do sometimes feel an expectation to perform procedures in clinic and to not refer, stand your ground if you feel that you do not have the skills to perform a task. Just because you're an urgent care clinician does not mean you have to have advanced skills in all areas of medicine. Our specialty is in identifying serious illness and referring appropriately, and while we do manage a lot in urgent care, nobody expects you to manage everything. Recognize your boundaries and always frame your decision around who would I want to do this procedure on my family member? Now if my family member had a felon, I would want a hand surgeon, so that is what I advocate for my patients too. So check out all the papers and the web pages mentioned in the show notes, and if you have any comments, questions, corrections or suggestions, please email podcast@rnzcuc.org.nz We'll be back again next week with another podcast. Look forward to seeing you all then, but for now, thanks for listening. [Music] [BLANK_AUDIO]
