Critical Cases - Paronychia!
- 26 yo female with pain, swelling of L 3rd digit over the past 2 days after biting off a hangnail
- No noted purulent discharge
- VS T 98.0 HR 95 BP 133/86 RR 18 Pox 100%
- L 3rd digit: swelling at the base of the L middle fingernail with tenderness or fluctuance
- No discharge
- Nail intact
- Digital nerve block for anesthesia
- I&D of the paronychia
- Warm soaks for the next few days
- Paronychia is an infection of the nail fold, usually from nail biting or ingrown nails
- The infection is polymicrobial with staph/strep and anaerobes
- If the paronychia is fluctuant or tense, it requires drainage by incising the tissue with a needle tip or scalpel parallel to the nail
- Post drainage care involved warm soaks, and possibly antibiotics if complicated by cellulitis or the patient is immunocompromised
Check out this quick video from Brown EM here for a real life demonstration!
Digit Block Pearls
- Place the patient's hand palm down
- Prep the area at the web space at the base of the finger bilaterally
- Insert a 27g or 25g needle dorsal to palmar just distal to the MCP joint at a 90 degree angle to the finger (see picture below)
- Inject 1.5-2 ml of lidocaine as you withdraw the needle
- Repeat on the other side
German, CA. “Nontraumatic Disorders of the Hand.” Tintinalli’s Emergency Medicine a Comprehensive Study Guide, 9th Edition.” (1914-1919).
Gibbs, MA, Wu, T. “Local and Regional Anesthesia.” Tintinalli’s Emergency Medicine a Comprehensive Study Guide, 9th Edition.” (236-248).
Photo from: “Paronychia, Causes and Treatment of an Infected Nail.” https://dailytophealth.com/health-news/paronychia-causes-and-treatment-of-an-infected-nail/ (12/21/2018)