Cellulitis With Felon

July 2, 2004
Brady Pregerson, MD
Brady Pregerson, MD

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 itprogressively worsened and was now “throbbing.” She denied fever andnail biting.

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 itprogressively worsened and was now "throbbing." She denied fever andnail biting.The patient was in moderate distress; temperature was 36.8C(98.3F); 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 appearedmore extensive than a paronychia. The swollen and slightly tender finger padwas neither fluctuant nor tense. Radiographs showed no bony involvement.Brady Pregerson, MD, of Los Angeles, anesthetized the finger with ethyleneoxide and lanced the abscess. A small amount of pus was expressed. BecauseDr Pregerson suspected a felon, he consulted a hand surgeon, who ultimatelydiagnosed cellulitis of the fingertip with early felon formation.The specialist performed a more extensive incision and drainage but didnot incise the finger pad. A No. 15 blade was used to continue the original incisiondown to the level of the distal phalanx. Immediate egress of purulent materialwas noted. Cultures of the purulent material were strongly positive forStaphylococcus aureus; the strain was not methicillin-resistant.An approximate 1-cm incision was created radially and laterally. Distal tissuewas excised to ensure complete removal of the roof of the abscess cavity.The wound was copiously irrigated with sterile normal saline, packed withiodoform gauze, and dressed with an antimicrobial bandage. A volar (or wristcock-up) splint was applied, and the hand was elevated with a pillow. Therapywith intravenous piperacillin/tazobactam was started, and the patient washospitalized for observation.After 2 days, the patient was discharged with instructions to change thedressing twice daily. She was advised to soak the affected digit in half-strengthhydrogen peroxide mixed with sterile normal saline for 20 minutes beforerepacking the wound and replacing the splint. She continued this regimenwith elevation and oral amoxicillin/clavulanate, 875 mg bid, for 10 days.A week after the splint was removed, the patient began to play the celloagain. The finger remained sensitive for about a month; no long-term sequelaewere reported.