Ingrown Toenails Chapter 14

What should be done if permanent ablation of nail bed is desired?

Ablation of the underlying nail matrix following nail removal may lower the rate of recurrence.

The needle w/ 0.5-1 mL of plain lidocaine is injected very slowly int the middle of the proximal nail fold. The lunula and nail bed will begin to blanch

Distal anesthesia though the proximal fold

Offers a total unit anesthesia. A needle w/ 2 mL of plain lidocaine is injected 2-3 mm proximal to the junction of the proximal and lateral nail fold.

Distal digital block (wing block)

Remove portions of the nail for easy exposure

Dual-action nail clippers

Type of bx used if melanoma is in the differential diagnosis

Excisional bx

Position of foot after toenail removal

Foot should be kept elevated for 24 to 36 hours with gradual return to ambulation.

Sensory supply to the great toe is through

Four digital nerves: both extensor and plantar branches of the medial and lateral nerves. They should be anesthetized before procedure

Used to avulse the nail while protecting the matrix

Freer septum elevator

Outward extension of the whitish nail matrix of proliferating epithelial cells that grows in a semilunar pattern. It pasts the posterior nail fold

Lunula

More effective care in preventing recurrence and regrowth on the ingrowing toenail.

Nail avulsion combined with phenol ablation

Excision orientation

Nail bed - longitudinally Nail matrix - horizontally

Should anesthesia be used before draining subungual hematoma?

No. It is often more painful than the procedure. If the hematoma is to be evacuated using a large-bore needle or scalpel blade, a digital block may be useful

Most common indication for the removal of a nail

Onychocryptosis (ingrown nail)

Used if permanent ablation of nail bed is desired

Phenol solution (88%)

Recommendation for hematoma involving 50% or more of the nail

Referred for nail removal and repair of the laceration

Tx of choice for ingrown toenails associated with painful swelling, inflammation and infection

Removal of part or all of affected nails. Pustular drainage may be noted if infection has occurred.

What if large lacerations of the nail bed are suspected?

Remove the nail, inspect the nailbed, repair any defects, clean the area, and reinserted the avulsed nail into place as a splint to protect the nailbed and keep the proximal nail fold open.

Can be applied to the nail bed to control bleeding after nail removal

Silver nitrate

how to decompress the nail hematoma

Trephination is performed by using an electric cautery device

True or False: The cutaneous sensory nerves run parallel to the blood vessels along the lateral digit

True

It should be avoided when anesthetizing a digit

Vasoconstricting agents such as epinephrine

Drainage of subungual hematoma CI

a. Crushed and fractured nails b. Fracture of the distal phalanx, which can be converted to an open c. suspected subungual melanoma d. cautery on artificial acrylic nails e. hematoma involving 50% or more of the nail (it may involve laceration of the underlying nail bed)

Types of distal digital anesthesia required for a nail bx

a. Distal digital block (wing block) b. Distal anesthesia though the proximal fold c. distal anesthesia though the hyponychium

Removal of a nail CI

a. bleeding diathesis b. allergy to local anesthesia c. DM or peripheral vascular disease should be considered on a case-by-case basis d. pregnant pts should not have phenol ablation

Removal of a nail potential complications

a. infection b. regrow of the nail and return of symptoms

Subungual hematoma drainage complications

a. make sure there is no underlying fx b. extensor tendon injury c. nail may fall off after drainage (it will grow back) d. pt should not soak finger (minimize infection) e. nail deformity (most likely complication) f. infection

Other indications for the removal of a nail

a. onychomycosis (fungal infection of the nail) b. chronic, recurrent paronychia (inflammation of the nail fold) c. onychogryposis (deformed, curved nail)

The nail bed consists of

all the tissue directly beneath the nail that functions in nail generation and migration. Richly innervated.

How can hemostasis be achieved?

by applying manual pressure to the lateral digital arteries during the procedures or by using a tourniquet w/ a flat Penrose drain.

How are nails derived?

by keratinization of cells from the nail matrix, which is located at the proximal end of the nail plate

When the anesthetic is injected through the web spaces along each side of the finger or toe

digital block

More painful for the pt and therefore is not performed often. The needle w/ plain lidocaine is inserted into the lateral hyponychium and directed horizontally in the nail bed while the lidocaine is injected.

distal anesthesia though the hyponychium

Hyponychium

distal ridge of the toe

The nail is avulsed prior to removing the specimen. The excision should be oriented along the longitudinal axis and the excision should d be elliptical. Defects larger than 3 mm should be sutured.

excisional bx

Inflammatory nail diseases include

functional melanonychia, lichen planus, psoriasis, and onychomycosis

Complications of Nail Biopsy

infection, hematoma, and nail deformity

What is considered a small subungual hematoma?

less than 25 % of nail involved

The nail is avulsed, and an excision is performed deep to the bone. The defect is closed w/ absorbable suture material. This is often used to diagnose longitudinal melanomychia. There is a higher risk for splitting of the nail.

longitudinal bx

Nail tumors include

melanoma, squamous cell carcinoma, pyogenic granulosa, and osteochondroma

Procedure w/ pathformer device

mesoscissioning procedure

Nail deformity is the result of

nail matrix damage

Device used to tx subungual hematoma

pathformer device

subungual hematomas are exceedingly painful injuries due to

pressure, which builds under the nail plate

Eponychium

proximal nail fold

Useful to sample the nail plate when a proximal white onychomycosis is suspected. It leaves a minimal scar and no suturing is necessary

punch biopsy

Most common type of nail biopsy include

punch biopsy, excisional bx, and longitudinal bx.

The nail plate consists of

the nail root embedded in the posterior nail fold, a fixed middle portion, and a distal free edge. Not innervated.

Anterioposterior and lateral x-rays of the affected digit often show a distal

tuft fracture

Most frequent indication to sample a nail unit

tumors

Nail bed blood supply

two terminal branches of the volar digital artery

Used for hemostasis

wide Penrose