History

• 26 yo female with pain, swelling of L 3rd digit over the past 2 days after biting off a hangnail
• No noted purulent discharge

Exam

• 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

Diagnosis

• Paronychia

Management

• Digital nerve block for anesthesia
• I&D of the paronychia
• Warm soaks for the next few days

Paronychia Pearls

• 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

References:

German, CA. “Nontraumatic Disorders of the Hand.” Tintinalli’s Emergency Medicine a Comprehensive Study Guide, 9^th 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)