This is an old “Pearl of the Day” I authored during residency. Thought of it after teaching how to drain a paronychia on shift, a less and less frequent procedure in the emergency department…
So back to our series of POTD’s based on my pet peeves. As residents eager to be trained, we are often eager... overeager for procedures. However, one rule that I keep at the forefront of my mind is this:
Don’t put holes in people unless you absolutely have to.
Yes, seems overly obvious. But it’s a concept that bears reiterating.
This sometimes means taking a breath and doing a little internal timeout before putting a chest tube in, or taking the extra time to check all available CVC sites before choosing one, to minimize your chance of having to change locations and poke again if the first attempt fails. Or like in today’s topic, opting to go for techniques that use existing holes rather than creating new ones.
... I’m typing ‘holes’ too much.
Today’s topic --
Paronychias
As the acuity goes up, we are seeing less and less fast track / split flow patients, so it’s good to review some of our simpler chief complaints.
Let’s get the definitions out of the way.
“Paronychia is an infection of the lateral nail fold or perionychium, occasionally extending to the cuticle or eponychium. It is usually caused by minor trauma such as nail-biting, manicures, or embed- ded lateral nails (“hangnails”). The infection often starts as a small area of induration that progresses to eponychial swelling, tenderness, erythema, and drainage. Most cases of paronychia contain both aero- bic and anaerobic bacteria, with S. aureus and Streptococcus species the most common aerobic bacteria cultured. Chronic paronychia (>6 weeks) can occur, particularly in patients who are immunocompro- mised, and may include usual pathogens or atypical bacteria and fungi such as with C. albicans.”
Chapter 283: Nontraumatic Disorders of the Hand: Paronychia (2016). Tintinalli's emergency medicine: A comprehensive study guide (Ninth edition.). New York: McGraw-Hill Education.
And the anatomy...
It can be mild to moderate to severe...
The treatment is pretty straightforward.
If unclear if the wound is fluctuant:
Apply pressure to the distal aspect of the affected digit, and examine for a larger than expected area of blanching, which could be representative of pus.
Ultrasound! Works well in a water bath.
How to Drain a Paronychia
The “pet peeve” part of this pearl of the day comes from watching practitioners not trialing the least invasive method of draining paronychias first. Sheath your 11 blades! (for now)!
For most abscesses, one might use a blade to incise over the area of fluctuance. However, most paronychias can be drained simply by lifting the nail fold off the nail plate to allow passive oozing of pus, theoretically following the same path as the initial bacteria that led to infection!
Here’s an image of the technique from the Practice of Surgery (1910). Groundbreaking, I know.
Often this technique can be done without anesthesia, but I typically still digital block these patients.
Clean the finger.
Anesthetize. This technique can often be done without a digital block, but I still typically do so for patient comfort. (A topic for a different day)
Lay one edge of a pair of suture removal scissors, push down on the nail fold and separate the fold from the nail bed. With gentle pressure, the pus will passively ooze.
For deeper cavities I often break up the pockets with the same blade and apply pressure to the inflamed skin until the pus has been evacuated.
No additional skin incision! No extra holes!
For more severe infections, a blade may need to be inserted directly into the eponychium, but try with the least invasive option first!
Below is a YouTube video where Dr. Larry Mellick performs a digital block then uses an 11-blade (though I prefer using the scissors as its bluntness has less of a risk of creating further damage) to first the separate the nail fold from the nail bed.
https://www.youtube.com/watch?v=BzarVK_7Jsk
Thanks all for reading :)