ED Clinical Pathway for the Evaluation/Treatment of the Child With a Suspected Deep Neck Space Infection URL: https://www.chop.edu/clinical-pathway/neck-infection-clinicalpathway Authors: R Abaya, MD; M Joffe, MD; L Vella, MD; M Dunn, MD; S MacFarland, MD; M Rizzi, MD; K Shekdar, MD; R Bellah, MD; J Lavelle, MD Posted: February 2017, reviewed October 2019 HAND AND FOOT LESIONS CLINICAL PEARLS AND PITFALLS Herpetic whitlow involving a finger is sometimes mistaken for a paronychia Consider hair tourniquets in the crying infant Ganglion cysts should not be incised in the ED but may require outpatient excision if painful or cosmetically concerning Trephination is the treatment of choice for uncomplicated subungual hematomas with intact nail margins regardless of the size of the hematoma Eponychia and Paronychia Infections and/or minor trauma of the digits are the major causes of hand lesions presenting to the ED The most common infections of the digits involve the eponychium (cuticle) as a result of a breakdown of the epidermal border due to trauma, traumatized hangnail, manicuring, finger sucking, or nail biting In its initial stage, the infection consists of a superficial cellulitis that remains localized to the cuticle and is termed an eponychia Symptoms include erythema and localized pain at the nail margin With progression, pus collects in a single thinwalled pocket under the cuticle, forming an acute paronychia ( Fig 120.1 ) Patients typically present with localized tenderness and have an area of fluctuance and purulence at the nail margin This may progress, extending under the skin at the base of the nail, and along the nail fold Less commonly, the pus burrows beneath the proximal nail, forming an onychia or subungual abscess Causative organisms include Staphylococcus aureus (including methicillin-resistant