A hematoma of the nail bed is relieved by making a hole in the nail (trephination) Restrain the child and digit on a table Cleanse the fingertip with antiseptic solution A high temperature, single use electrocautery pen can be used to melt a hole through the nail This technique is rapid and often less painful than making a hole with other methods ( Fig 130.36A ) If electrocautery is not readily available, options include heating the tip of a paper clip held with a hemostat used in a manner similar to electrocautery or the use of an 18-gauge needle or no 11 scalpel in a rotary motion to bore a hole through the nail Enter perpendicular to the nail in the center of the hematoma If using an 18-gauge needle, apply gentle downward pressure and rotary motion by rolling the hub of the needle back and forth between your fingertips to eventually create a hole in the nail, as shown in Figure 130.36B (needle/scalpel) and Figure 130.36C (heated paper clip) Apply gentle pressure to the nail bed for several minutes after the hole has been made to facilitate drainage, and then cover with a sterile dressing FIGURE 130.36 Drainage of a subungual hematoma INCISION AND DRAINAGE OF A FELON Indications A felon, or digital pulp space abscess, requires drainage to relieve severe pain and to decrease the spread of infection Complications Scar formation Bleeding Procedure The use of procedural sedation may be a useful adjunct to digital block in an anxious child Have an assistant hold the hand supinated on a table top Locate the felon in the pulp space ( Fig 130.37A ) between the volar soft tissues and the periosteum of the distal phalanx The incision should be made at the site of maximal tenderness Anesthetize the finger with a digital nerve block, as described in Procedure Digital and Metacarpal Nerve Block After anesthesia is achieved, cleanse the fingertip with antiseptic solution Don sterile gloves Make a longitudinal incision ( Fig 130.37B ) over the site of maximal tenderness using a no 11 scalpel blade A felon is an abscess and should be drained where it points, just like any other abscess When pus is encountered, enlarge the incision to the proximal and distal limits of the abscess FIGURE 130.37 Incision and drainage of a felon Do not divide the septa Previously described techniques, such as the “fishmouth” and lateral incisions, are associated with iatrogenic complications These include skin slough, permanent anesthesia, unstable fat pad, pain, and an unsightly scar After drainage, place a small gauze wick in the opening ( Fig 130.37C ) to keep the wound edges separated Place a bulky dressing, and immobilize the hand with a short forearm splint In 24 to 48 hours, remove the dressing and inspect the wound Subsequent dressing changes may be done every days Systemic antibiotics are recommended INCISION AND DRAINAGE OF A PARONYCHIA Indications Failure of a superficial infection of the soft tissue along the edges of the nail to respond to medical treatment or the development of pus beneath the surface Complications Bleeding Scar formation Spread of infection if the cause is herpetic whitlow Procedure Consider anxiolysis with midazolam in anxious children In most instances, a digital block with 1% lidocaine is recommended as described in Procedure Digital and Metacarpal Nerve Block In older cooperative patients, the use of ethyl chloride spray over the site to be lanced may be sufficient for anesthesia Cleanse the site ( Fig 130.38A ) with antiseptic solution Using a no 11 scalpel blade, incise the skin at its junction with the nail This can be accomplished by sliding the blade under the skin parallel to the surface of the nail As indicated in Figure 130.38B , extend the incision along the base of the nail to permit adequate drainage If the paronychia only involves one side of the nail, make the incision along the lateral margin of the nail distal to the cuticle To keep the wound open, placement of a gauze wick at the lateral margin of the nail may be useful Dress the wound Occasionally, the purulence may be located under the corner of the nail itself necessitating removal of a small portion of the nail to ensure adequate drainage If any portion of the nail is to be removed, a digital block should be employed for anesthesia INGROWN TOENAIL REPAIR Indications Pain and edema secondary to infection which fails to respond to conservative management Complications Bleeding Damage to nail matrix or structures below nail bed Spread of infection Recurrence of ingrowth Abnormal or absent nail regrowth Procedure