Wednesday, August 20, 2008

Paronychia

This past weekend I treated my own paronychia. Haven't figured out how I developed it, as I had no hang nails, don't chew on my fingernails, no recognized trauma to the digit. I initially treated the red, tender area around the nail with antibiotic ointment and a Band-Aid (to keep the ointment in place and to protect the area from any further injury). At first there was no "fluctuant area" and no localized pus pocket. That was until Sunday morning. Check out the photo I took with my new iPhone (my husband's birthday gift to me). Being a seamstress, there are plenty of needle around my house. I sterilized one and gently lifted the top off the localized pus. I would not recommend that just anyone do this. Remember I am a trained professional.

Here is a repost of my article from last August:

Felons and paronychia make up one third of all hand infections. The thumb and index finger are most often involved. Wooden splinters or minor cuts are common predisposing causes, yet over half of patients will give no history of injury.

Felons are closed-space infections of the fingertip pulp (padding beneath the finger print area). Fingertip pulp is divided into numerous small compartments by vertical septa that stabilize the pad. Infection occurring within these compartments can lead to abscess formation, edema, and rapid development of increased pressure in a closed space. This increased pressure may compromise blood flow and lead to necrosis of the skin and pulp. It is most often caused by staph aureus. Felons that are untreated, are incorrectly treated, or have a prolonged course may lead to osteomyelitis. X-rays evaluation of the bone should be done in severe cases.

Treatment is incision and drainage. This will remove any pus present, but will also reduce the pressure within the closed compartment and restore blood flow.

  1. The finger can be numbed with local anesthesia (digital block).
  2. Make short skin incision with a number 11 blade over the area of maximum tenderness. Incise only the skin with scalpel. Do not cross the DIP joint crease (can create a contraction)
  3. Evacuate any pus (and culture) using a blunt instrument, like a small hemostat. This will decrease the chance of injury to the digital nerve or the tendon sheath (can lead to acute tenosynovitis). Do not divide vertical fascial strands (septa) as this makes the fingertip pulp unstable.
  4. Pack gauze loosely into the wound to prevent skin closure. Apply a loose dressing, splint finger, and elevate hand above the heart.
  5. Followup in 2-3 days.

Incision Tips:

A longitudinal incision in the midline is effective without serious iatrogenic complications (nerve injury, tendon sheath injury). Lateral or transverse incisions frequently cause ischemia and anesthesia by injuring one or both neurovascular bundles. If a lateral incision is used, it is best to incise the non-contact aspect of the finger (ulnar side of fingers, radial side of the thumb). Fish-mouth incision can lead to an unstable painful fingertip.

Empirical antibiotic coverage for S aureus and streptococcal organisms should be provided. Given the rapid emergence of community-acquired methicillin-resistant S aureus, treatment with a drug more likely to be effective against this agent should be considered. Coverage for E corrodens may be indicated for immunosuppressed patients. Dicloxacillin, erthromycin, Keflex, nafcillin, and Bactrim DS are good ones to start the patient on while waiting for the culture. The recommended length of treatment varies from five to 14 days and depends on the clinical response and severity of infection.


Complications:
Osteomyelitis involving the distal phalanx.

The most serious complication is acute tenosynovitis. It may result from natural, contiguous spread of infection. It most often iatrogenic from inadvertent nicking of flexor tendon sheath with scalpel.

Other complications include skin necrosis, deformity of the fingertip, septic arthritis, and instability of the finger pad.


REFERENCES

Infections of the Hand: A Guide to the Surgical Treatment of Acute and Chronic Suppurative ... By Allen Buckner Kanavel (Google eBook)

Wheeless' Textbook of Orthopedics Online

Common Acute Hand Infections--AAFP

Felon by Glen Vaughn, MD--eMedicine article

7 comments:

purplesque said...

Super cool. Hubby did an I&D on his big toe last week with a no. 11 blade. I offered to help, then stuck my head under the pillow. It has since healed..good luck with your finger!

rlbates said...

My finger is already healed. Looks great! Thanks. Hope your hubby's toe is doing well.

WhiteCoat said...

Thanks for another neat "how to" article. Just like purplesque, we just had to take care of the same thing on my daughter's toe.
Glad that the infection is better.

Dr. Val said...

Yikes, I hope you don't get osteomyelitis. :-/

rlbates said...

Val, my finger is already healed! but thanks for the concern.

Julie Curtis/El Dorado native said...

Glad to know what was wrong with my index finger a few weeks ago. I developed redness and a pus pocket at the base of my nail. No splinters, cuts, etc. It looked exactly like the picture on your post.
I drained it and put antibiotic salve on it and it finally healed after a couple of weeks. Now my fingernail is misshapen at the base of the nailbed. A big dent in it, if you will. I suppose it will grow off.

Anonymous said...

You should publish a case report on this to get wider coverage!