Subungual Hematoma, Ingrown Toenail
You could also used
#11 scalpel 18 guage needle but may need digital block
Complications:
*permanent nail deformity Infection Cautery may cause inadvertent burn causing permanent damage Functional deficits (numbness)
Post-op care:
- foot elevated 24-36 hours - analgesics for pain - change dressing in 24 hours - soak toe in warm water 2x per day - look for signs of infection
Complications
-Infection
Follow-up care:
-Small dab of abx ointment on the nail 2x daily - soaked in warm, soapy water 2-3x daily -light dressing until site closes
Contraindications
-bleeding diathesis -allergy to local anesthesia
to prevent recurrence
-low heeled shoes with room for forefoot and toes - not to trim the nails to short and trim in a flat straight across fashion
Indications
-onychocryptosis (ingrown) -onychomyosis (fungal infection of the nail) -chronic paronychia (inflammation of nail fold) -onychogryposis (deformed, curved nail bed)
Procedure:
1. Sitting/Supine 2. Document size 3. Assess for fractures 4. Treat for fracture 5. Digit soaks in antiseptic solution, wash off alcohol with sterile water or allow to dry 6. Burn small hole in the nail with microcatery or paper clip (2-3x) 7. Make 1-2 mm hole 8. Clean with alcohol wipes 9. Abx ointment and dressing
Procedure:
1. Supine 2. Scrub toe with betadine and sterile drape 3. 5mL local anesthetic into syringe 4. inject local in a ring around toe (dorsal --> plantar) 5. apply tourniquet to base of toe or use penrose drain with hemostat. 6. Partial: cut the nail lengthwise with sterile scissors or nail cutters 4-5 mm from affected fold 7. Entire: cut down the middle 8. Loosen and lift nail with narrow periosteal elevator or flat edge of scissor. 9. Separate nail from nail bed by applying upward pressure 10. Ablation 11. Dry nail bed with sterile gauze 12. apply 88% phenol solution for 3 mins 13. Neutralize with alcohol 14. remove tourniquet 15. Abx ointment to nail bed with sterile nonadherent gauze 16. wrap toe with rolled or tubular gauze 17. hard soled shoe for several days
Subungual hematoma are challenging to treat why?
BC of the inability to observe the extent of nail bed laceration.
Subungual Hematoma Define:
Injury to the nail bed of fingers and toes
Simple trauma
Results in bleeding into the space between the nail bed and fingernail
Nail bed is
Richly innervated tissue responsible for nail generation and migration
Subungual Hematoma caused by:
Simple trauma Repetitive, indirect trauma to the distal end of the nail plate
Repetitive, indirect trauma to the distal end of the nail plate
Tight fitting shoe
Silver nitrite can be used for
bleeding control
DM and PVD pts
case-by-case basis try conservative measures referral if still necessary
Artificial acrylic nails are falammable and what should be avoided
cautery
Artificial acrylic nails are flammable and what should be avoided
cautery
Contraindications
crushed or fractured nails Fracture of distal phalanx Subungual melanoma Artificial acrylic nails Hematomas >50% of nail bed
If pressure is not relieved
damage to the nail matrix and the germinal layer may occur
This damage can cause
delayed regrowth dystrophy of the nail plate
Sensory supply to great toe
digital nerves that have extensor and plantar branch
Nail plate and nail bed are supported by
distal phalanx
Conservative measures
elevation of nail plate with cotton wick soaking loose-fitting shoes trimming of nails
The size of the hematoma is not directly related to the possibility of
fracture
Which toe is usually affected
great toe *either the medial or lateral border are involved
if using a paper clip it must be held with
hemostat heat the straightened portion of the paper clip with a lighter until the tip is red hot
Nail trauma requires:
history physical examination radiography
Improper trimming of the nail results in
impingement, inflammation and infection in the surrounding and overlying skin of the nail fold.
Most frequent underlying cause
improper trimming of the nail Also improperly fitted shoes that compress toes together change of shape to nail or increased curvature of lateral edges
Pt presents with
intense pain secondary to pressure caused by the hematoma
Nails are derived from
keratinization of cells from nail matrix at proximal end of nail plate
Ingrown toenails can cause
limitation in function and mobilty
Nail plate is produced by
matrix nail bed
if permanent removal of the nail is desired
matrix of the nail bed must be ablated.
Nail plate consists of
nail root in poster nail fold fixed middle portion distal free edge
If the nail bed is not cauterized
nail will regrow and symptoms may return
What is common with ingrown toenails
pain along the margin of the toenail erythema swelling infection: pustular drainage
Notify practitioner if
pain persists change in sensation, purulent or foul-smelling drainage, fever, erythema
Drainage of the hematoma provides
pain relief and decreases the secondary pressure
Definitive treatment
partial or total removal of nail
If the nail bed is cauterized
potential still exists for regrowth and return of symptoms
Nail avulsion and phenol
prevents recurrence and regrowth
Indications:
relief from the acute pain associated with visible, painful subungual hematoma
Primary goal of treatment
relieve the pressure
Whitish nail matrix of proliferating epithelial cells grows
semilunar pattern called the lunula
if nondisplaced fracture is suspected you
splint until swelling improves *radiograph when fracture is suspected
Position during procedure
supine or sitting
inform patients that
the nail may spontaneously fall off
After the blood has drained, the pain should improve significantly, if not think
underlying fracture
Nail bed is supplied by
volar digital artery