The Daily Differential — Monday, May 11, 2026

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Paronychia Incision and Drainage

Paronychia I&D is a high-yield ED procedure that rapidly relieves pain and prevents spread. Technique matters because unnecessary incisions can injure the...

At the Bedside

Indications

Fluctuant abscess at lateral/proximal nail fold.
Visible pus under nail fold.
Failure of conservative therapy with worsening swelling/pain.

Contraindications / caution

Herpetic whitlow: grouped vesicles, burning pain, HSV exposure → do not incise.
Significant immunocompromise, extensive cellulitis, deep infection → consider consultation/antibiotics.
Concern for felon, flexor tenosynovitis, or osteomyelitis → broaden evaluation.

Preparation

Explain procedure, risks: bleeding, pain, recurrence, nail deformity, incomplete drainage.
Position hand well; use bright lighting.
Consider soaking first to soften tissue.
Sterile prep; gloves.
Digital block if needed, though small paronychias can sometimes be drained without full block.

Technique options

Needle lift technique: insert an 18-gauge needle bevel-up under the lateral/proximal nail fold and gently lift to allow drainage.
Scalpel lift technique: use No. 11 blade with sharp edge away from nail bed; slide between nail plate and nail fold to open abscess.
Small lateral incision: if abscess does not drain with lifting.
Subungual extension: may require partial nail plate removal.
Proximal nail fold/eponychial abscess: avoid aggressive matrix injury; consider hand follow-up if extensive.
Irrigate gently after drainage.
Packing usually unnecessary for simple paronychia.
Dress with nonadherent gauze.
Warm soaks at home 3–4 times daily.

Aftercare

Recheck in 24–48 hours if significant infection, immunocompromise, incomplete drainage, or antibiotics started.
Return precautions: worsening pain, spreading erythema, fever, finger pad swelling, decreased ROM, numbness, streaking.

Disposition

Most go home after I&D.
Consult hand surgery for:
Nail matrix disruption.
Extensive subungual abscess.
Recurrent/complex infection.
Deep-space extension.
Concern for felon or tendon sheath infection.

A Classic Presentation

A 41-year-old woman presents after a manicure with 3 days of increasing pain and swelling at the proximal nail fold. Exam shows a small collection of pus beneath the eponychial fold without finger pad swelling. After a digital block, an 18-gauge needle is used to gently lift the nail fold, releasing purulence. The wound is irrigated, dressed, and she is discharged with warm soaks and return precautions; no antibiotics are prescribed because there is no cellulitis or systemic illness.

Study Directive

Practice describing the procedure aloud in under 60 seconds, including consent risks and aftercare.
Review digital nerve block anatomy and max local anesthetic dosing.
Watch one paronychia I&D video and identify where the blade edge should face.
Make a decision tree: no abscess → soaks; abscess → I&D; cellulitis/MRSA/oral flora/immunocompromise → consider antibiotics.
Review photos of paronychia vs herpetic whitlow vs felon.

Key Medications

Lidocaine 1% without epinephrine: typical digital block 3–5 mL total; max 4.5 mg/kg.
Lidocaine 1% with epinephrine: generally safe in digits in healthy patients; max 7 mg/kg, but avoid in severe peripheral vascular disease, crush/avulsion with vascular compromise, Raynaud’s, or ischemic digit.
Bupivacaine 0.25–0.5%: longer anesthesia; max generally 2–2.5 mg/kg without epinephrine. Use caution and check reference if mixing anesthetics.
Topical antibiotic ointment: bacitracin or mupirocin thin layer after drainage.
Cephalexin: 500 mg PO QID x 5–7 days if cellulitis/MSSA-strep coverage needed.
TMP-SMX DS: 1–2 tabs PO BID x 5–7 days if MRSA risk.
Amoxicillin-clavulanate: 875/125 mg PO BID x 5–7 days if nail biting/oral flora exposure.
Pediatric local anesthetic and antibiotic dosing is weight-based; verify with a pediatric dosing reference.

High-Yield Pearls

The goal is to separate the nail fold from the nail plate, not to cut deeply into the nail matrix.
Antibiotics do not replace drainage when pus is present.
Herpetic whitlow mimics paronychia but I&D can worsen outcomes and increase viral spread.

Board Question

During drainage of a simple acute paronychia, which technique is most appropriate?

ADeep transverse incision across the fingertip pulp
BNeedle or No. 11 blade elevation of the affected nail fold
CComplete nail removal in all cases
DIncision through grouped vesicles to prevent spread

Reveal answer

Correct: B

Simple paronychia abscesses are usually drained by lifting the nail fold with an 18-gauge needle or No. 11 blade. Deep pulp incisions are for felons, complete nail removal is not routine, and grouped vesicles suggest herpetic whitlow, which should not be incised.

Recent Literature

Review or guideline Management of Finger Felons and Paronychia: A Narrative Review
J Emerg Med, 2025

EM-focused review covering when paronychia needs drainage, how to distinguish it from felon, and practical procedural approaches including nail-fold elevation or partial nail removal.

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Pediatric Lower Extremity Fractures

Children fracture through growth plates, metaphyses, and pliable bones differently than adults. Missed physeal injuries, occult toddler fractures,...

At the Bedside

Initial approach

ABCs first in high-energy trauma.
Assess pain, deformity, open wounds, bleeding.
Document neurovascular exam before and after reduction/splinting:
Pulses, cap refill, skin temperature.
Motor/sensory exam appropriate to age.
Compartment firmness and pain with passive stretch.
Look for associated injuries: pelvis, spine, abdomen, head.
In nonambulatory children or inconsistent history, consider nonaccidental trauma.

Key pediatric fracture concepts

Salter-Harris injuries: physeal injuries can be radiographically subtle.
Buckle/torus fractures: compression failure, stable.
Greenstick fractures: one cortex breaks, other bends.
Plastic deformation: bone bends without obvious fracture line.
Toddler fracture: nondisplaced spiral tibial shaft fracture in young ambulatory child with limp/refusal to bear weight.

Common lower extremity patterns

Femur fracture
High-energy in older kids; NAT concern in nonambulatory infants.
Pain, deformity, shortening, swelling.
Can cause significant blood loss.
Immobilize with traction or long-leg splint depending on setting; consult ortho.
Toddler tibia fracture
Age ~9 months–3 years, limp/refuses to walk, minimal swelling.
Initial x-ray may be negative.
Immobilize if high suspicion; repeat imaging or ortho follow-up.
Tibial shaft fracture
Watch for compartment syndrome.
Long-leg splint/cast, ortho follow-up or admission depending displacement.
Ankle physeal injuries
Distal tibia/fibula Salter-Harris common.
Tenderness over physis matters even if x-ray subtle.
Immobilize; ortho follow-up.
Tillaux/triplane fractures
Transitional adolescent ankle fractures.
Often need CT and ortho involvement.
Foot/metatarsal fractures
Assess Lisfranc injury: midfoot swelling, plantar ecchymosis, pain with forefoot stress.

Imaging

AP/lateral views; include joint above and below for long bones.
Oblique views for ankle/foot when needed.
Comparison views rarely needed but can help in young children.
CT for intra-articular, complex, triplane/Tillaux, pelvic injuries.
MRI if occult fracture, stress injury, osteomyelitis vs fracture uncertainty.
POCUS can help detect cortical disruption or effusion but does not replace required radiographs in most cases.

ED management

Analgesia early.
Remove constricting clothing/shoes.
Irrigate/cover open fractures; give antibiotics promptly.
Reduce obvious deformity or neurovascular compromise emergently.
Splint in position of comfort if no emergent reduction needed.
Recheck neurovascular status after splinting.
Elevation and ice.
Non-weight bearing instructions and crutches/walker if appropriate.

Disposition decision points

Admit/urgent ortho:
Open fracture.
Neurovascular compromise.
Compartment syndrome concern.
Femur fracture.
Displaced physeal fracture.
Intra-articular fracture.
Uncontrolled pain.
Polytrauma.
NAT concern.
Discharge with ortho follow-up:
Stable nondisplaced fractures.
Buckle-type injuries.
Suspected toddler fracture after immobilization.
Reliable caregivers and clear return precautions.

A Classic Presentation

A 2-year-old refuses to bear weight after twisting while running. There is no deformity, but he cries with palpation over the distal tibia. Initial tibia/fibula x-rays are read as negative. Because the exam is classic for toddler fracture, he is placed in a long-leg splint or walking boot depending local practice and age, given analgesics, and discharged with ortho follow-up and repeat imaging instructions.

Study Directive

Memorize Salter-Harris I–V and draw each pattern from memory.
Review x-rays of toddler fracture, distal tibial SH injuries, Tillaux, triplane, and femur fracture.
Practice documenting a pediatric lower extremity neurovascular exam.
Build a splint guide: posterior long-leg, stirrup, posterior short-leg, traction splint indications.
Review your institution’s pediatric procedural sedation and open-fracture antibiotic protocols.

Key Medications

Acetaminophen: 15 mg/kg PO/PR q6h PRN; max single dose 1,000 mg; max daily dose generally 75 mg/kg/day up to 3,000–4,000 mg depending age/risk.
Ibuprofen: 10 mg/kg PO q6–8h PRN; max single dose 600 mg in many ED protocols; avoid in renal disease/dehydration/GI bleeding risk.
Fentanyl intranasal: 1.5–2 mcg/kg IN once; may repeat per protocol. Useful before IV access.
Fentanyl IV: 1 mcg/kg IV q30–60 min PRN, titrate carefully.
Morphine IV: 0.05–0.1 mg/kg IV q2–4h PRN; titrate to effect.
Ketamine analgesic-dose: 0.1–0.3 mg/kg IV for severe pain; institutional protocols vary.
Ketamine procedural sedation: 1–2 mg/kg IV or 4–5 mg/kg IM; dosing/monitoring varies—use institutional sedation protocol.
Open fracture antibiotics:
- Cefazolin: pediatric commonly 30 mg/kg IV, max 2 g per dose; adult 2 g IV, or 3 g if very high body weight per protocol.
- Add gram-negative/anaerobic coverage for severe contamination per institutional open-fracture protocol.
Tetanus: update based on immunization and wound risk.

High-Yield Pearls

Growth plate tenderness after trauma is a fracture until proven otherwise.
Pediatric bones fail by buckling, bending, or incomplete cortical disruption; x-rays can be subtle.
Compartment syndrome in children may present as increasing analgesic requirement, anxiety, and agitation rather than classic adult findings.

Board Question

A 30-month-old child refuses to walk after a low-energy twisting injury. Exam shows focal tibial tenderness, but initial radiographs are normal. What is the best next step?

AReassure the parents and allow full activity
BImmobilize for suspected toddler fracture and arrange follow-up
COrder emergent angiography
DPerform arthrocentesis of the knee

Reveal answer

Correct: B

Toddler fractures are often occult on initial radiographs. A child with refusal to bear weight and focal tibial tenderness should be immobilized with appropriate follow-up even if initial x-rays are negative.

Recent Literature

Review or guideline The Toddler's Fracture
Pediatr Emerg Care, 2022 · cited 13×

Practical ED-focused review of toddler’s fractures, emphasizing suspicion despite subtle or negative initial x-rays, appropriate immobilization, and follow-up for limping toddlers with tibial pain.

4 of 4

Pediatric Upper Extremity Fractures

Upper extremity fractures are among the most common pediatric ED injuries. Supracondylar fractures, lateral condyle fractures, and forearm fractures can...

At the Bedside

Initial assessment

Mechanism: fall on outstretched hand, fall from height, sports, bike/skateboard, direct blow.
Inspect for deformity, swelling, open wounds, skin tenting.
Palpate clavicle, shoulder, humerus, elbow, forearm, wrist, hand.
Assess compartments, especially forearm.
Document neurovascular exam before and after reduction/splinting.

Key neuro exam

Median nerve: sensation index finger; motor thumb opposition.
Anterior interosseous nerve: “OK sign”/pinch strength.
Radial nerve: wrist/finger extension; dorsal first webspace sensation.
Posterior interosseous nerve: finger/thumb extension, no sensory deficit.
Ulnar nerve: finger abduction/adduction; small finger sensation.
Check radial/ulnar pulses, cap refill, hand warmth.

Common upper extremity fractures

Clavicle fracture
Common; sling, analgesia.
Watch skin tenting, open fracture, neurovascular injury.
Proximal humerus fracture
High remodeling potential in younger children.
Sling/immobilizer unless markedly displaced.
Supracondylar humerus fracture
Usually FOOSH; extension type most common.
Look for anterior/posterior fat pad, anterior humeral line disruption.
High risk: brachial artery injury, median/AIN injury, compartment syndrome.
Gartland:
Type I: nondisplaced → posterior long-arm splint, ortho follow-up.
Type II: displaced with intact posterior cortex → ortho; often operative depending alignment.
Type III/IV: displaced/unstable → urgent ortho, often operative pinning.
Lateral condyle fracture
Can be subtle; intra-articular and prone to nonunion.
Requires ortho follow-up; displaced often operative.
Medial epicondyle fracture
Associated with elbow dislocation; fragment may incarcerate in joint.
Radial head/neck fracture
Pain with pronation/supination.
Both-bone forearm fracture
Deformity common; reduction often needed.
Monitor for compartment syndrome.
Distal radius/ulna buckle fracture
Stable; removable splint often appropriate.
Distal radius physeal fracture
Immobilize; reduction if significantly displaced.
Scaphoid fracture
Snuffbox tenderness; x-ray may be negative.
Thumb spica and follow-up if suspected.

Imaging

AP/lateral views of injured area.
Include joint above and below for forearm/humerus injuries.
True lateral elbow critical for fat pads and alignment lines.
Oblique views for lateral condyle or scaphoid when needed.
Comparison films sometimes helpful in young children.
CT rarely needed but useful for complex intra-articular injuries.

ED management

Early analgesia.
Remove rings/bracelets.
Immobilize with appropriate splint:
Sling: clavicle/proximal humerus.
Posterior long-arm: elbow/supracondylar/lateral condyle/radial neck.
Sugar-tong: forearm/distal radius when swelling expected.
Volar wrist or removable splint: buckle fracture.
Thumb spica: suspected scaphoid.
Reduce if:
Neurovascular compromise.
Severe deformity.
Skin tenting/impending open injury.
Significant displacement per ortho guidance.
Repeat neurovascular exam after reduction/splint.

Disposition decision points

Urgent ortho/admission/transfer:
Open fracture.
Pulseless, pale, cold hand.
Nerve deficit with displaced fracture.
Displaced supracondylar fracture.
Compartment syndrome concern.
Floating elbow: ipsilateral supracondylar + forearm fracture.
Incarcerated medial epicondyle after elbow dislocation.
Displaced lateral condyle.
Discharge with close follow-up:
Buckle fractures.
Nondisplaced clavicle.
Nondisplaced supracondylar type I.
Suspected scaphoid with thumb spica.
Stable nondisplaced distal radius/ulna injuries.

A Classic Presentation

A 6-year-old falls from monkey bars onto an outstretched hand and presents with elbow swelling and pain. X-ray shows a posterior fat pad and posterior displacement of the distal humerus consistent with an extension-type supracondylar fracture. Exam reveals weak “OK sign” but warm hand with palpable pulse. The arm is immobilized in a posterior long-arm splint, analgesia is given, neurovascular findings are documented, and orthopedics is urgently consulted for likely operative management.

Study Directive

Practice reading pediatric elbow films: anterior humeral line, radiocapitellar line, fat pads.
Drill the pediatric hand neuro exam: AIN, PIN, radial, median, ulnar.
Review Gartland classification and management implications.
Make a splint list for clavicle, supracondylar, both-bone forearm, buckle, and scaphoid injuries.
Review reduction/sedation workflow with your department’s pediatric ketamine checklist.

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Mechanism Pearl of the Day: Children’s bones and fingertip soft tissues both fail according to anatomy: pediatric growth plates and flexible cortices create subtle fracture patterns, while fingertip septae trap infection under pressure. In both, understanding the compartment or structural weak point predicts the complication—growth arrest, compartment syndrome, pulp ischemia, or deep-space spread.

Key Medications

Acetaminophen: 15 mg/kg PO/PR q6h PRN; max single dose 1,000 mg.
Ibuprofen: 10 mg/kg PO q6–8h PRN; max single dose often 600 mg depending protocol.
Fentanyl IN: 1.5–2 mcg/kg IN once; may repeat per protocol.
Fentanyl IV: 1 mcg/kg IV titrated to effect.
Morphine IV: 0.05–0.1 mg/kg IV.
Ketamine procedural sedation: 1–2 mg/kg IV or 4–5 mg/kg IM; follow institutional sedation policy.
Hematoma block for distal radius reduction: lidocaine 1% commonly 5–10 mL in older children/adolescents; dose must remain below mg/kg maximum. Check institutional pediatric guidance.
Cefazolin for open fracture: pediatric commonly 30 mg/kg IV, max 2 g; adult 2 g IV, 3 g if very high body weight per protocol.
Tetanus: update as indicated.

High-Yield Pearls

Posterior fat pad after elbow trauma is an occult fracture until proven otherwise.
Supracondylar fracture + forearm fracture = “floating elbow,” with higher compartment syndrome risk.
A warm pink pulseless hand after supracondylar fracture still requires urgent orthopedic involvement.

Board Question

A child with an extension-type supracondylar humerus fracture cannot make an “OK sign” but has intact pulses and capillary refill. Which nerve is most likely injured?

AUlnar nerve
BAxillary nerve
CAnterior interosseous nerve
DMusculocutaneous nerve

Reveal answer

Correct: C

The anterior interosseous nerve, a branch of the median nerve, controls flexor pollicis longus and the radial portion of flexor digitorum profundus, producing the “OK sign.” It is classically injured in extension-type supracondylar fractures.

Recent Literature

Recent clinical Diagnostic value of artificial intelligence-based software for the detection of pediatric upper extremity fractures
Eur Radiol, 2026 · cited 1×

AI fracture-detection software may serve as an adjunct for ED interpretation of pediatric upper-extremity radiographs, where subtle elbow, wrist, and forearm fractures are commonly missed.

Full text · open access

TheDaily Differential

Paronychia and Felon

At the Bedside

Study Directive

Recent Literature

More in Today's Issue

Paronychia Incision and Drainage

Pediatric Lower Extremity Fractures

Pediatric Upper Extremity Fractures

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