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



  • Paronychia



  • 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



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.” (12/21/2018)