Consider anxiolysis with midazolam in anxious children Procedural sedation may be necessary A digital block with 1% lidocaine is always recommended as described in Procedure Digital and Metacarpal Nerve Block Cleanse the site with antiseptic solution A digital tourniquet can be applied once the digit has been anesthetized to minimize bleeding Depending on the extent of the lesion, an angular (or wedge), partial, or complete nail resection may be required An Angular (or Wedge ) nail resection involves removing the distal portion of the nail including the nail spicule Elevate the nail by inserting the tip of a hemostat or scissors under the nail parallel to the nail bed Advance it slowly with a side-to-side or open and close motion and without damaging the nail matrix Use a nail cutter or pointed scissors to cut to approximately one-third to one-half the way to the proximal nail fold and remove a triangular wedge of nail containing the spicule ( Fig 130.39A ) File down the cut edge of the nail, and debride and cleanse the exposed nail bed without damaging the nail groove Apply antibiotic ointment and a nonadherent dressing A Partial nail resection involves removal of the lateral one-fourth to one-third of the nail edge Insert the tip of a hemostat or scissors under the distal edge of the nail plate and parallel to the nail bed Slowly advance it to the level of the eponychium with a side-to-side or open and close motion and without damaging the underlying nail matrix Use a nail cutter or sharp pointed scissors to cut the nail one-fourth to one-third the distance from the lateral edge of the nail and proximally through the eponychium to ensure the nail root is excised ( Fig 130.39B , part A) A hemostat should be used to grab the lateral nail segment and remove it using a gradual steady rotating motion toward the remaining nail edge to minimize damage and resect the segment in one piece ( Fig 130.39B , part B) Examine the resected portion to ensure it contains the nail root as desired Debride and clean the now exposed nail bed ( Fig 130.39B , part C) A strip of gauze or cotton can be placed beneath the cut intact nail edge to elevate it slightly and avoid recurrence Apply antibiotic ointment and a nonadherent dressing FIGURE 130.38 Incision and drainage of a paronychia FIGURE 130.39 A : Angular nail resection B : Partial nail resection (Incision [A ], Nail segment removal [B ], Debridement [C ]) (A, B : Reprinted with permission from King C, Henretig FM, King BR, et al Textbook of Pediatric Emergency Procedures 2nd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2008.) A Complete nail resection is rarely necessary but may be considered if the lesion is extensive or is ingrown on both sides of the nail The procedure is similar to a partial nail resection except the entire nail plate is gently separated from the nail bed and proximal nail fold before removal REMOVAL OF A SUBUNGUAL SPLINTER OR FOREIGN BODY Indications Painful subungual splinter To prevent infection or a foreign-body reaction to a splinter in the nail bed Complications Bleeding Infection Procedure The key to successfully completing this procedure is adequate anesthesia With all but the most superficial splinters/foreign bodies, a digital block should be performed to achieve anesthesia Restrain the child’s hand with the fingers extended ( Fig 130.40 A) If the splinter end is visible, it may be possible to pull it out directly with tweezers or a hemostat Otherwise, scissors can be inserted and spread under the distal tip of the nail to lift the nail from the bed allowing for improved access to the splinter/foreign body, or a no 11 scalpel blade can be used to scrape the nail down to the nail bed to uncover enough of the splinter/foreign body to remove it The latter technique is likely to be associated with less pain after the anesthetic wears off Hold the blade perpendicular to the direction of the splinter and at 90 degrees from the horizontal, as in Figure 130.40B Scrape the nail off in a proximal to distal fashion, applying pressure gently to minimize discomfort from squeezing the nail onto the splinter The shape of the nail removed is similar to that of a “U.” With small tweezers or forceps, grasp the splinter/foreign body once it is exposed and tug it gently to remove it from the nail bed ( Fig 130.40C ) Irrigate the area with sterile saline after removal and dress with antibiotic ointment and a bandage FIGURE 130.40 Removal of a subungual splinter or foreign body Large splinters or those embedded deeply under the nail are best removed by excision of a portion of the nail after a digital block ... ]) (A, B : Reprinted with permission from King C, Henretig FM, King BR, et al Textbook of Pediatric Emergency Procedures 2nd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2008.) A Complete