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
