Onychocryptosis

What is the Frost procedure?

"L" shaped incision behind nail plate Excise the nail root (penetrate epi, dermis, and subcutaneous tissue)

What individuals are at risk for nail surgical procedures?

Allergy to local anesthetics Coagulapathy Pregnancy PAD

Involves sharp partial or total excision of the nail matrix and/or the nail bed

Cold steel procedures

What is the Winograd procedure?

D shaped excision of nail root and overlying tissues Semi-elliptical incision

Distal ring of tissue develops and nail growth blocked by hyponychium; allows dorsal (upward) expansion of nail

Distal nail embedding

Are oral antibiotics necessary in the treatment of locally infected ingrown toenails?

Do not play a role in decreasing healing time or post-procedure morbidity

What supplies the medial side of the great toe dorsally?

Dorsal digital branches (from medial and dorsal cutaneous nerves)

What is Stage 1 of onychocryptosis?

End of toe red with mild swelling May feel warm and painful to touch No pus/drainage

What instrument is used to split the nail plate?

English Anvil

What are individuals with PAD defined as?

Exertional leg symptoms Non-healing wounds 65 y/o + 50 y/o + with hx of smoking or diabetes < 50 y/o with diabetes and one addtnl risk factor

T/F: Glomus tumor is malignant

FALSE -- benign tumor but painful

What procedure is used for subungual exostosis?

Fowler procedure

What are types of partial nail excision procedures?

Frost Winograd

Tender, red, subungual nodule or small, subtle area of blue pigmentation

Glomus tumor

What is the Zadik procedure?

H shaped incision Excision of entire nail matrix and nail bed

Characterized by an overgrowth of soft tissue of the internal portion of the lateral nail fold

Hypertrophy of lateral nail fold

What is the Fowler procedure?

Incision angles ~45 degrees from nail border Excision just at nail root

What is Stage 2 of Onychocryptosis?

Increasingly red, swollen and painful Maybe white or yellow colored pus or drainage Infection may have developed

What is onychocryptosis?

Ingrown toenail -- painful cut of nail into surrounding skin causing inflammatory reaction

What is the Whitney procedure?

Inverted L on BOTH SIDES (nail borders) *similar to Frost*

Impingement of nail plate onto nail fold due to improper nail cutting; spicule pierces soft tissue

Juvenile Ingrown Toenail

What are the multiple clinical presentations of onychocryptosis?

Juvenile ingrown Hypertrophy of nail fold Pincer/Involuted nail Distal nail embedding

What are hallux blocks used for?

Onychocryptosis Paronycha Skin biopsy Closed reduction

Which group showed less pain and earlier pain relief between cold steel vs. phenol procedures?

Phenol group

Nail plate displays an excessive curvature, especially in distal portion Results in compression of distal nail bed with severe pain

Pincer Nail (Trumpet Nail/Omega nail/ Involuted nail)

What type of clinical presentation of onychocryphosis are good candidates for surgical correction?

Pincer nails

What supplies the skin on the medial side of the great toe?

Proper digital nerve of great toe

Lobar capillary hemangioma; common benign vascular lesion of skin and mucosa

Pyogenic Granuloma

What is Stage 3 of Onychocryptosis?

Redness, swelling and pain increased Granulation tissue adds to swelling and discharge Lateral nail fold hypertrophy More severe infection; fever

What agents are used for granuloma management?

Silver nitrate Lumican (coagulant)

Subungual pigmentation that does not move distally as the nail plate grows Locally destructive; highly metastatic

Subungual/ Periungual melanoma

Procedure used in the belief that the nail matrix is all emcompassing around the nail base

Suppan procedure

How should the hemostat be rotated to removed the nail piece?

TOWARDS THE NAIL while pulling straight out toward end of toe

T/F: Sodium hydroxide causes less postop morbidity and provides faster recovery than phenol

TRUE

What supplies the adjacent sides of the great and second toes?

Terminal branch of deep peroneal nerve

What is Hutchinson's sign?

Think Melanoma Spilling over into skin/adjacent nail folds

What type of excision procedure is used for patient with hypertrophied borders?

Winograd procedure

What are types of total nail excision procedures?

Zadik Whitney Fowler Kaplan Suppan Terminal symes

Where is a hallux block injected?

distal to 1st MPJ

Describe the directions of injection for the hallux block procedure?

dm to pm, dm to dl, dl to pl

What is the underlying cause of ingrown toenails? what type of HS reaction?

foreign body reaction Type IV

What is onychophosis?

hyperkeratotic tissue develops on lateral or proximal nail fold between folds and nail plate

What portion of the matrix contributes to the top layer of the nail plate?

proximal portion (distal portion = ventral side of nail)

What is a true exostosis?

something falls on top of nail/trauma produces more bone --> painful