Paronychia Incision and Drainage (Abscess at Fingernail)

Indications for Paronychia I and D

Paronychia is an infection and abscess located in the pads of the fingertips

Contraindications

Streptococcal infections – these generally are treated with antibiotics

Cellulitis with abscess of localized prurulent collection.

Diagnosis

History and physical – this is important as the severity and extent of the paronychia infection can be partially determined by the precipitating event and duration and location of the infection.

It must be remembered that infections in the volar surface (i.e., palm side) of the hand and finger somewhat paradoxically usually present with impressive swelling in the dorsal surface (i.e., back side). Incisions are only made in the dorsal surface if there is actual fluctuance appreciated.

Plain radiographs (X-rays) – these are sometimes obtained to check for the presence of air in the finger tissues that might indicate anaerobic bacteria are involved.

Computed tomography (CT) – this is done rarely to ascertain proximal involvement of the abscess.

Magnetic resonance imaging (MRI) – this test is extremely useful in diagnosis and treatment of hand conditions, including paronychia abscesses and infection and is the gold standard in imaging modalities of the hand. MRIs of the hand do not require contrast media.

Preoperative Work-up and Preparation

Antibiotics – On an outpatient basis, Augmentin is commonly prescribed as it has a broad-spectrum antibiotic coverage. Bactrim is used on an outpatient basis in suspected cases of MRSA paronychia. Intravenous antibiotics used include cefazolin (Ancef) and vancomycin.

Elevation and immobilization – this strategy is adopted if the infection has not completely formed a definable collection.

Glucose control – this is paramount in diabetics as it is difficult to clear infections if the patients are hyperglycemic (high serum glucose.)

Anesthesia

Felon drainage is typically done under regional or local blocks. Regional blocks may be done at the level of the brachial plexus or the axillary nerve. Wrist blocks may be done at the level of the radial nerve (for the thumb and forefinger), ulnar nerve (for the ring and 5th finger) and the median nerve.

Digitabl blocks can be carried out for the affected finger but should be performed in the web space on either side of the affected finger, never at the base. Injections at the base of the finger risks ischemia of the digit due to the inability of the tissues to expand to hold the volume of injection.

Surgical Details of Procedure