Thursday, June 2, 2016
A Kinder, Gentler Approach for Felons
I have serious issues with the current management recommendations for fingertip felons. I hate the thought of blindly "slicing and dicing" fingertips as treatment. I agree that fingertip abscesses should be drained, but I really question whether current approaches are the best. Thankfully, the really aggressive techniques of the past such as the through-and-through, hockey stick, or fish mouth incisions are no longer recommended. Currently, the unilateral longitudinal approach and the volar finger pad longitudinal approaches are recommended in textbooks. Unfortunately, even these recommendations are based purely on consensus and have almost no supporting evidence-based literature. The research is essentially nonexistent, and these treatment recommendations come from consensus opinions based on clinical experience. (J Hand Surg Am 2012;37:2603.)
It's possible, however, that even these incision and drainage techniques may be unnecessary in a large percentage of these infections. The problem is that ultrasound adapted to avoid near field acoustic distortion is not being used consistently. Documentation of an abscess clearly justifies an intervention. It's entirely possible, however, that a simple large bore needle aspiration of the abscess may be the only intervention needed in addition to appropriate oral antibiotics. I agree that these infections are a compartment syndrome of the finger pad. These fingertip infections are not your typical compartment syndrome, however.
The compartment of the fingertip is actually 15 to 20 small compartments, which means the normal, healthy finger pad is divided into multiple small compartments by 15 to 20 septa that extend from the periosteum to the skin. Consequently, the same 18-gauge needle used to aspirate an abscess can be redirected to decompress these tiny, engorged compartments. It's highly possible that we have accomplished a kinder and gentler compartment release if the fingertip is vigorously massaged after the needle decompression to express fluid from the compartments through the needle tracks.
My agenda for wanting to find something less invasive is because the fingertip is rich with sensory nerves and blood vessels. I could not find a study, but I strongly suspect that the residual morbidity of the current approach with the fingertip incision and drainage procedure is significant and includes finger pad instability, pain, and numbness. We must find a kinder and gentler, evidence-based approach to treating felons.
Watch a video demonstrating techniques for treating felons.