205: Nail Surgery Flashcards
(248 cards)
1
Q
What are the main objectives of nail surgery?
A
The main objectives of nail surgery include:
- Aid diagnosis by biopsy
- Treat infection
- Alleviate pain
- Remove local tumors
- Ensure the best cosmetic results in acquired and congenital abnormalities
2
Q
What are the perioperative considerations in nail surgery?
A
Key perioperative considerations include:
- Providing an exact illustration of the operation to give insight into the procedure and expected outcome.
- Discussion on postoperative morbidity is essential.
3
Q
What risks and precautions should be taken into account before nail surgery?
A
Risks and precautions include:
- History taking to reveal systemic diseases that may contraindicate surgery.
- Awareness of medications that may affect anesthesia or healing.
- Avoiding surgery in patients with high-risk conditions.
- Monitoring for potential complications such as infection or necrosis.
4
Q
What is the anatomy of the nail plate and its components?
A
The anatomy of the nail plate includes:
- Nail Plate: Permanent product of the nail matrix, covering the dorsal aspect of the digit.
- Matrix: Extends under the proximal nail fold, with the distal portion visible as the lunula.
- Nail Bed: Extends from the lunula to the hyponychium, providing a firm attachment to the nail plate.
- Cuticle: Seals and protects the nail cul-de-sac.
- Hyponychium: Marks the point where the nail separates from the underlying tissue.
5
Q
What are the sensory and vascular components associated with the nail apparatus?
A
The sensory and vascular components include:
- Digital Arteries: Supply the nail apparatus and give off branches to the distal and proximal arches.
- Sensory Nerves: Provide sensation to the distal phalanx of the fingers, with branches from the dorsal collateral nerves.
- Nail Functions: Provides counterpressure to the pulp, essential for tactile sensation and prevention of hypertrophy of the nail bed.
6
Q
What perioperative considerations should be taken into account for patients with systemic diseases?
A
Systemic diseases like diabetes and chronic pulmonary disease may be relative contraindications to surgery. They are associated with severe complications such as infection and necrosis, and may require alterations in surgical techniques.
7
Q
What precautions should be taken for patients with a history of aspirin use before nail surgery?
A
Aspirin use can prolong bleeding. It is important to assess the patient’s medication history and take necessary precautions to manage bleeding during and after surgery.
8
Q
What imaging techniques can be used to confirm a suspected tumor in the proximal nail matrix?
A
Ultrasonography and MRI are recommended when a tumor is suspected in the proximal nail matrix.
9
Q
What is the primary function of the cuticle in nail anatomy?
A
The cuticle seals and protects the nail cul-de-sac, preventing infections and maintaining the integrity of the nail apparatus.
10
Q
Why is it important to use a magnifying lens and dermoscopy during nail surgery?
A
Magnifying lens and dermoscopy help observe the color, surface, and structure of the periungual tissue, and allow comparison with the unaffected contralateral digit.
11
Q
What is the role of the germinal matrix in nail anatomy?
A
The germinal matrix forms the bulk of the nail plate and contributes to its growth and structure.
12
Q
What factors should be considered during patient selection for nail surgery?
A
Factors to consider during patient selection include:
- Providing an exact illustration of the operation to give insight into the procedure and expected outcome.
- Discussion on postoperative morbidity is essential.
- History taking may reveal systemic diseases that could be contraindications to surgery or associated with severe complications.
13
Q
What are the risks associated with nail surgery in patients with a history of systemic diseases?
A
Patients with a history of systemic diseases may face:
- Relative contraindications to surgery.
- Increased risk of severe complications such as infection or necrosis.
- Potential need for alteration of the surgical technique used.
14
Q
How does the use of certain medications affect nail surgery?
A
The use of certain medications can affect nail surgery in the following ways:
- Monoamine oxidase inhibitors or phenothiazines may affect anesthesia.
- Aspirin and anticoagulants can prolong bleeding.
- Glucocorticoids may delay healing.
- Retinoids can have toxic effects on the nail apparatus.
15
Q
What is the significance of the nail matrix in nail surgery?
A
The nail matrix is significant because:
- It is the source from which the nail plate is derived.
- It extends approximately 6 mm under the proximal nail fold.
- The distal portion is visible as the white semicircular lunula, which is crucial for nail growth and health.
16
Q
What role does the cuticle play in nail health?
A
The cuticle serves several important functions:
- It seals and protects the nail cul-de-sac.
- It prevents pathogens from entering the area beneath the nail plate.
- It contributes to the overall integrity and health of the nail apparatus.
17
Q
What are the basic requirements for performing nail surgery?
A
The basic requirements for nail surgery include:
- Detailed knowledge of the anatomy and physiology of the nail apparatus.
- Full aseptic conditions.
- Regional block anesthesia.
- Local hemostasis to minimize bleeding during the procedure.
18
Q
What is the function of the nail bed in relation to the nail plate?
A
The nail bed functions as:
- A firm attachment point for the nail plate.
- A highly vascular connective tissue that transmits a pink color through the nail.
- It plays a role in the overall health and growth of the nail.
19
Q
How does the anatomy of the proximal nail fold contribute to nail surgery?
A
The proximal nail fold contributes to nail surgery by:
- Providing a roof for the pocket-like invagination where the nail is inserted.
- Serving as a landmark for identifying the nail matrix during surgical procedures.
- Its integrity is crucial for the normal appearance and growth of the nail.
20
Q
What is the importance of postoperative photographs in nail surgery?
A
Postoperative photographs are important because they:
- Serve as a useful medicolegal record of the surgical procedure and outcomes.
- Help in assessing the healing process and any complications that may arise post-surgery.
- Provide a reference for future treatments or surgeries if needed.
21
Q
What are the key considerations for administering local anesthesia during nail surgery?
A
- Positioning: Patient should be reclining or in a supine position.
- Anesthetic Options: Use Lidocaine 1% or 2% due to low allergy incidence; Buffered 2% lidocaine and ropivacaine for quick absorption.
- Pre-application: Applying Emla or LMD 2 hours prior can lessen pain, especially in children.
- For Anxious Patients: Administer fast-acting benzodiazepines (e.g., midazolam) 2 hours before.
- Epinephrine Use: Local anesthesia with epinephrine is now acceptable for digit surgeries, aiding vasoconstriction and reducing bleeding.
- Caution: Be cautious with patients at risk for circulatory insufficiency.
22
Q
What is the procedure for a proximal digital block in nail surgery?
A
- Technique: Lay the hand flat with fingers spread.
- Injection: Administer 1 to 2 mL of anesthetic via dorsal injection, inserting a thin needle tangentially to the sides of the bony phalanx at the base of the involved finger.
- Tourniquet Effect: Avoid injecting more than 5 mL to prevent a tourniquet effect.
- Verification: Ensure absence of blood reflux in the syringe before injection.
- Localized Block: For localized operations, a block limited to the nerves ipsilateral to the lesion is sufficient.
23
Q
What are the steps involved in draping for nail surgery?
A
- Use a sterile surgical drape or a sterile glove on the involved hand.
- Cut the tip of the glove off the finger for surgery.
- Roll back the remaining open finger of the glove down the digit.
- Exsanguinate the digit and apply a tourniquet at the proximal part of the finger.
- Disinfect to avoid contamination, using isopropyl alcohol scrub or chlorhexidine, which are superior to povidone iodine washing.
24
Q
What are the advantages of using buffered 2% lidocaine for local anesthesia in nail surgery?
A
Buffered 2% lidocaine offers quick absorption and near-instantaneous anesthesia, making it effective for nail surgery.
25
What pre-anesthesia medication can be administered to reduce fear in anxious patients?
Fast-acting benzodiazepines like midazolam, alprazolam, or diazepam can be given orally 2 hours before anesthesia to reduce fear.
26
What is the main advantage of a proximal digital block over a distal digital block?
A proximal digital block is less painful than a distal block, although it takes 5 to 10 minutes for anesthesia to become established.
27
What are the key considerations for administering local anesthesia in nail surgery?
- Administer while the patient is reclining or supine.
- Use Lidocaine 1% or 2% due to low allergy incidence.
- Buffered 2% lidocaine and ropivacaine for quick absorption.
- Apply Emla or LMD under occlusion 2 hours prior to injection for pain reduction.
- For anxious patients, consider fast-acting benzodiazepines 2 hours before.
- Ropivacaine offers rapid onset and long duration (8-12 hours).
- Caution for patients with risk factors for circulatory insufficiency.
- Buffering and warming the anesthetic can reduce injection pain.
28
What is the procedure for performing a proximal digital block in nail surgery?
1. Position the hand flat with fingers spread.
2. Administer 1 to 2 mL of anesthetic via dorsal injection.
3. Insert a thin needle tangentially to the sides of the bony phalanx at the base of the involved finger.
4. Ensure the injection reaches the lateral side of the flexor tendon.
5. Avoid injecting more than 5 mL to prevent a tourniquet effect.
6. Verify absence of blood reflux in the syringe before injection.
29
What are the advantages of using buffered local anesthetics in nail surgery?
- Quick absorption and near instantaneous anesthesia.
- Reduced pain during injection due to buffering.
- Improved patient comfort and satisfaction.
- Allows for effective vasoconstriction when used with epinephrine, leading to a less bloody surgical field.
30
What is the importance of disinfection in nail surgery preparation?
- Disinfection is crucial to avoid contamination of the wound.
- It helps prevent consecutive infections post-surgery.
- Isopropyl alcohol scrub and chlorhexidine are superior to povidone iodine for disinfection.
31
What is the role of a tourniquet in nail surgery, and how is it applied?
- A tourniquet is used to exsanguinate the digit and reduce blood flow during surgery.
- It is applied by rolling back the remaining open finger of a sterile glove down the digit until it reaches the proximal part of the finger.
32
What are the potential risks associated with local anesthesia in patients with circulatory insufficiency?
- Increased risk of complications due to reduced blood flow.
- Potential for inadequate anesthesia or prolonged recovery.
- Careful monitoring and adjustment of anesthetic techniques are essential to mitigate risks.
33
How does the administration technique differ between proximal and distal digital blocks?
| Block Type | Administration Technique |
|---------------------|-----------------------------------------------------------------------------------------|
| Proximal Digital | Dorsal injection with a thin needle directed tangentially to the bony phalanx. |
| Distal Digital | Injection at the level of the distal phalanx, often requiring a different approach. |
34
What are the key instruments required for nail surgery?
| Instrument | Purpose |
|-----------------------------------|----------------------------------------------|
| Nail elevators | To lift and remove nails. |
| Double-action bone nippers | For cutting bone. |
| Scissors | For cutting soft tissue. |
| Small hemostats | To control bleeding. |
| Disposable biopsy punches | For obtaining tissue samples. |
35
What is the significance of verifying blood reflux in the syringe before injection?
- Ensures that the needle is correctly positioned in the tissue and not in a blood vessel.
- Prevents complications such as systemic toxicity from anesthetic entering the bloodstream.
- Confirms that the anesthetic will be effective in the targeted area.
36
What are the advantages of using ropivacaine in nail surgery?
- Provides a rapid onset of action.
- Offers a long duration of anesthesia (8-12 hours).
- Lower risk of toxicity compared to other local anesthetics.
- Effective for both proximal and distal digital blocks.
37
What is the preferred method of anesthesia in the absence of a digital bacterial infection?
The preferred method of anesthesia is the distal digital block, which is more painful than the proximal block but provides immediate anesthesia.
38
What is the technique for median distal administration of anesthetic?
The needle is introduced at a 30° angle into the middle of the proximal nail fold and advanced distally into the underlying matrix, injecting anesthetic slowly as it pierces the nail plate, matrix, and adjacent nail bed.
39
What is the purpose of using a tourniquet during nail surgery?
The tourniquet is used to strict surgical ischemia to avoid bleeding and enable a correct visualization of the operative field.
40
What are the postoperative care instructions for dressing after nail surgery?
At the end of the operation, the digit is cleansed, covered with antiseptic or antibiotic ointment, and a bulky compressive dressing is applied. Dressings should not be removed in the first 48 hours and should be changed every other day or daily if there is infection.
41
What is the significance of adding epinephrine to lidocaine during nail surgery?
The addition of epinephrine to lidocaine may reduce the need for a tourniquet and produce better and longer pain control perioperatively.
42
What is the preferred method of anesthesia for procedures on the proximal half of the nail unit?
Median distal administration is suitable for most procedures performed on the proximal half of the nail unit.
43
What is the recommended technique for achieving a bloodless surgical field during nail surgery?
A digital tourniquet or exsanguinating tourniquet is recommended for achieving a bloodless surgical field.
44
What is the primary risk of leaving a tourniquet on for too long during nail surgery?
Leaving a tourniquet on for too long can lead to digital necrosis. It is recommended not to leave it on for more than 15 to 20 minutes.
45
What is the purpose of using a Penrose drain as a tourniquet in nail surgery?
A Penrose drain provides prolonged bloodless field by being placed around the base of the digit and secured with a hemostatic clamp.
46
What is the recommended dressing protocol immediately after nail surgery?
The digit should be cleansed with sterile 10% hydrogen peroxide solution, sprayed with a disinfectant, and covered with an antiseptic or antibiotic ointment on gauze or pads.
47
What is the preferred method of anesthesia in the absence of a digital bacterial infection and how is it administered?
The preferred method of anesthesia is a distal digital block. It is administered by inserting a needle just behind the junction of the proximal nail fold and a lateral nail fold, injecting a few tenths of a milliliter of anesthetic, and then aiming the needle toward the pad. The injection is continued by returning to the initial area to inject the proximal fold transversely.
48
What are the key steps in performing a median distal administration of anesthetic?
1. Introduce the needle at a 30° angle into the middle of the proximal nail fold.
2. Advance the needle distally into the underlying matrix.
3. Inject anesthetic slowly as the needle pierces the nail plate, matrix, and adjacent nail bed.
4. Confirm delivery of anesthetic by observing blanching of the nail plate.
49
What is the purpose of using a transthecal block in nail surgery?
The transthecal block is used to introduce anesthetic to the core of the digit through the flexor tendon sheath, allowing for rapid anesthesia of all four digital nerves. This technique involves injecting lidocaine or ropivacaine into the potential space of the flexor tendon sheath.
50
In what scenarios is general anesthesia preferred for nail surgery?
General anesthesia is preferred in more extensive and painful surgeries or when anesthesia of more than one digit is required at the same time, such as in the surgical treatment of numerous warts or in the treatment of nail unit psoriasis.
51
What precautions should be taken when using a tourniquet during nail surgery?
1. Ensure strict surgical ischemia to avoid bleeding and enable visualization of the operative field.
2. Do not leave the tourniquet on for more than 15 to 20 minutes.
3. Interrupt the tourniquet application for a few minutes during longer procedures.
4. Never forget the tourniquet on, as it can lead to digital necrosis.
52
What is the recommended procedure for dressing after nail surgery?
1. Cleanse the digit with sterile 10% hydrogen peroxide solution and apply a colorless disinfectant or antiseptic with hemolytic action.
2. Cover the nail area with an antiseptic or antibiotic ointment on gauze or pads.
3. Ensure the dressing accounts for oozing, pain, and sensitivity.
4. Apply a bulky dressing for cushioning against local trauma and maintain compressive dressing for the first 48 hours.
53
What is the significance of blanching during the administration of a distal digital block?
Blanching during the administration of a distal digital block confirms the delivery of anesthetic to the nail matrix and bed, indicating that the anesthetic is effectively reaching the target area for pain control.
54
What are the potential complications of using a tourniquet during nail surgery?
Potential complications include digital necrosis if the tourniquet is left on for too long, and inadequate blood flow which can lead to tissue damage. It is crucial to monitor the duration of tourniquet application and ensure proper technique to minimize risks.
55
How should dressings be managed postoperatively to prevent infection?
Dressings should be changed every other day or daily if there is evidence of infection. It is important to maintain a compressive dressing for the first 48 hours to prevent excessive oozing and to protect the surgical site from infection.
56
What is the role of epinephrine in lidocaine during nail surgery?
The addition of epinephrine to lidocaine may reduce the need for a tourniquet and provide better and longer pain control perioperatively by constricting blood vessels and prolonging the anesthetic effect.
57
What is the recommended dressing technique for post-operative care of nail surgery?
Several layers of sterile gauze should be kept in place by Micropore tape in a U shape. A circular dressing should not be applied in the first week. X-span tube dressing or Surgitube can be used for more freedom, but care must be taken to avoid constricting blood flow. The arm should be kept in a sling for the first 48 hours, and stitches are removed after 7 to 12 days.
58
What are the key considerations for managing bleeding post nail surgery?
Bleeding after the tourniquet is removed is not worrisome as the compressive dressing will stop it. For persistent bleeding, apply 35% aluminium chloride solution or oxidized cellulose (Gelfoam). An extra injection of lidocaine with epinephrine can also help stop the bleeding through vessel compression.
59
What are the pain management strategies recommended after nail surgery?
Pain management includes CO2 laser vaporization for warts and chemical matricectomy as the least painful procedures. Larger excisions may require more potent painkillers. Elevating the extremity during the first 48 hours is advised to prevent swelling and reduce pain. Weak opioids and NSAIDs can be used for moderate pain, while strong opioids are reserved for intense pain.
60
What is the significance of dysesthesia following nail surgery?
Dysesthesia is a known occurrence after nail surgery, with complete or partial resolution noted after 6 to 12 months. It is important to monitor and manage this condition as part of postoperative care.
61
What are the infection prevention measures recommended for patients undergoing nail surgery?
Prophylactic antibiotic treatment is mandatory for patients with prosthetic valves and those at risk for joint prosthesis infection. Tetanus toxoid should be advised for toe lesions, especially in farmers. Thorough preoperative cleaning and broad-spectrum antibiotics can help prevent wound infection.
62
What are the potential complications associated with nail avulsion?
Nail avulsion can lead to complications such as necrosis from tight stitches, hypertrophic scars, and keloids. Reflex sympathetic dystrophy, now known as 'Complex regional pain syndrome' Type I, is rare but can present with pain sensitivity and motor disturbances.
63
What are the advantages of the proximal approach in nail avulsion?
The proximal approach prevents injury to the distal nail bed and hyponychium. It allows for careful insertion of the spatula under the base of the nail plate where adherence is weak, facilitating easier removal of the nail plate while minimizing damage to surrounding tissues.
64
What is the recommended approach for managing residual dystrophies after nail surgery?
Residual dystrophies are not uncommon when surgery involves the proximal area of the matrix. Nail spicules can be observed after lateral longitudinal excision, lateral matricectomies, or total removal of the nail apparatus, indicating the need for careful postoperative monitoring and management.
65
What is the recommended postoperative care for a patient who has undergone nail surgery on the foot?
The patient should wear an appropriate shoe or sandal, remain recumbent for 24 to 48 hours with the foot elevated to 30°, and perform daily chlorhexidine baths.
66
What is the first-line treatment for postoperative bleeding that persists despite compressive dressing?
Apply 35% aluminum chloride solution or oxidized cellulose (Gelfoam) to stop persistent bleeding.
67
What is the recommended treatment for postoperative pain following CO2 laser vaporization of warts?
CO2 laser vaporization of warts is one of the least painful procedures, and moderately potent oral analgesics can help manage any discomfort.
68
What are the key postoperative care instructions for a patient after nail surgery involving the toes?
- Keep the foot elevated to 30° for 24 to 48 hours.
- Wear an appropriate shoe or sandal after dressing.
- Daily chlorhexidine baths should precede care.
- Stitches are removed after 7 to 12 days.
- The arm must be kept in a sling for the first 48 hours.
69
What should be done in case of persistent bleeding after nail surgery?
- Apply 35% aluminium chloride solution or oxidized cellulose (Gelfoam).
- An extra injection of lidocaine with epinephrine can be given to stop bleeding through vessel compression.
70
What are the recommended pain management strategies following nail surgery?
- Use CO2 laser vaporization for less painful procedures.
- Administer moderately potent oral analgesics for pain control.
- Elevate the extremity during the first 48 hours to reduce swelling and pain.
- Use weak opioids or NSAIDs for moderate pain, and restrict strong opioids to intense pain.
71
What is the significance of dysesthesia following nail surgery?
Dysesthesia is a known occurrence post-surgery, with complete or partial resolution noted after 6 to 12 months, indicating the need for patient monitoring and potential management strategies.
72
What prophylactic measures should be taken to prevent infection in patients undergoing nail surgery?
- Administer prophylactic antibiotics for patients with prosthetic valves or joint prostheses.
- Advise tetanus toxoid for toe lesions, especially in farmers.
- Ensure thorough preoperative cleaning to prevent infection.
73
What are the potential complications associated with nail avulsion?
- Necrosis from tight stitches.
- Hypertrophic scars and keloids, though rare.
- Implantation epidermoid cysts may occur in operation scars.
- Reflex sympathetic dystrophy, presenting with pain and motor disturbances.
74
What are the advantages of the proximal approach in nail avulsion?
- Prevents injury to the distal nail bed and hyponychium.
- Allows for easier detachment of the nail plate from its underlying bed.
- Reduces the risk of complications associated with distal approaches.
75
What is the process for performing a distal approach in nail avulsion?
1. Insert a Freer septum elevator or dental spatula between the nail plate and nail bed.
2. Use proximal force to detach the nail from its bed without injuring longitudinal ridges.
3. Grasp one of the lateral edges with a hemostat and extract it with an upward circular movement.
76
What are the clinical implications of residual dystrophies after nail surgery?
Residual dystrophies can occur when surgery involves the proximal area of the matrix, leading to nail spicules or deformities that may require further intervention or monitoring.
77
What is the recommended action if a bulky dressing is blood-stained after 24 hours post-surgery?
The dressing should be changed to prevent infection and ensure proper healing.
78
What are the signs that may indicate an infection after nail surgery?
- Pulsating pain beginning 36 to 48 hours post-surgery.
- Blood-stained dressings after 24 hours.
- Increased swelling or redness around the surgical site.
79
What is the role of broad-spectrum antibiotics in preoperative care for nail surgery?
Broad-spectrum antibiotics should be initiated to prevent postoperative infection, especially in patients with risk factors such as prosthetic devices or poor hygiene.
80
What are the potential outcomes of acquired nail malalignment?
Acquired nail malalignment may result from lateral longitudinal biopsy exceeding 3 mm, leading to cosmetic and functional issues that may require corrective procedures.
81
What is the clinical significance of reflex sympathetic dystrophy in nail surgery patients?
Reflex sympathetic dystrophy, now known as Complex Regional Pain Syndrome Type I, presents with pain sensitivity and motor disturbances, indicating a need for comprehensive pain management strategies.
82
What should be done if a patient experiences strong pain after nail surgery?
Strong opioids should be administered for intense pain, while monitoring for signs of infection or other complications that may require intervention.
83
What are the key considerations for postoperative care in patients with prosthetic valves undergoing nail surgery?
- Mandatory prophylactic antibiotic treatment to prevent infection.
- Close monitoring for signs of infection post-surgery due to increased risk.
84
What is the importance of proper dressing techniques after nail surgery?
Proper dressing techniques prevent constriction of blood flow, reduce the risk of infection, and promote optimal healing conditions for the surgical site.
85
What are the potential complications of using a circular dressing in the first week after nail surgery?
Using a circular dressing can constrict blood flow, leading to complications such as necrosis or delayed healing, which is why a U-shaped dressing is recommended instead.
86
What is the recommended management for postoperative pain in patients undergoing larger excisions?
More potent postoperative painkillers should be used, along with strategies to keep the patient comfortable and in control of their pain management.
87
What are the signs of postoperative infection that should be monitored after nail surgery?
- Increased pain or swelling at the surgical site.
- Redness or warmth around the area.
- Discharge or pus from the wound.
88
What is the significance of using chlorhexidine baths before caring for treated feet post-surgery?
Chlorhexidine baths help reduce the risk of infection by ensuring the surgical site is clean before dressing changes or other care activities.
89
What are the potential risks associated with tight stitches after nail surgery?
Tight stitches can lead to necrosis of the tissue, delayed healing, and increased risk of scarring or keloid formation.
90
What is the recommended approach for managing postoperative dysesthesia?
Monitor the patient for symptoms and provide reassurance, as complete or partial resolution may occur within 6 to 12 months; consider pain management strategies if necessary.
91
What are the clinical implications of using a proximal approach for nail avulsion?
The proximal approach minimizes the risk of injury to the distal nail bed and allows for easier detachment of the nail plate, reducing complications during the procedure.
92
What should be done if a patient shows signs of infection after nail surgery?
Initiate appropriate antibiotic therapy based on culture results and monitor the patient closely for any worsening symptoms or complications.
93
What are the potential complications of nail surgery that involve the proximal area of the matrix?
Residual dystrophies and nail spicules may occur, which can lead to cosmetic concerns and may require further surgical intervention.
94
What is the recommended action for a patient experiencing intense pain after nail surgery?
Administer strong opioids for pain relief and assess for any signs of complications that may require further intervention.
95
What is the role of routine nail cleansing before surgery?
Routine nail cleansing softens the nail plate and minimizes contamination, reducing the risk of postoperative infection.
96
What is the recommended treatment for acute paronychia that does not respond to antibiotics within 48 hours?
Surgical removal of the base of the nail plate is recommended for acute paronychia unresponsive to antibiotics.
97
What is the purpose of nail biopsies?
Nail biopsies are performed to:
- Determine the **histopathologic features** of a lesion
- Clarify an **uncertain clinical diagnosis**
- Techniques depend on the **location of the lesion**
98
What is the best technique for diagnosing inflammatory disorders of the nail?
The **lateral longitudinal biopsy** is the best technique for diagnosing inflammatory disorders such as **lichen planus** or **psoriasis** when all subunits of the nail apparatus are involved.
99
What is the maximum size for a punch biopsy of the distal nail matrix to avoid serious dystrophy?
A **3-mm punch biopsy** is the maximum size that does not produce serious dystrophy, although even biopsies of this size can cause such effects if carried out in the most proximal portion of the nail matrix.
100
What is the significance of the origin of longitudinal melanonychia in nail biopsies?
Establishing the **matrix origin** (proximal or distal) of longitudinal melanonychia is important preoperatively because the more proximal the origin, the greater the risk of **nail dystrophy**.
101
What technique is claimed to give the best cosmetic results in nail surgery?
The **tangential matrix biopsy** technique is claimed to give the best cosmetic results. It involves cutting and reclining the proximal portion of the nail plate to expose the pigmented lesion, followed by its tangential removal.
102
What is the recommended biopsy technique for diagnosing inflammatory disorders like lichen planus or psoriasis?
Lateral longitudinal biopsy or lateral fusiform excision is the best technique for diagnosing inflammatory disorders.
103
What is the recommended biopsy technique for wide longitudinal melanonychia?
Tangential matrix biopsy is a good option for wide longitudinal melanonychia.
104
What is the primary purpose of performing a nail biopsy?
To determine the **histopathologic features** of a lesion and to clarify an uncertain clinical diagnosis.
105
What is the recommended technique for diagnosing inflammatory disorders involving all subunits of the nail apparatus?
The **lateral longitudinal biopsy** is the best technique for diagnosing inflammatory disorders such as **lichen planus** or **psoriasis**.
106
What is the maximum size for a punch biopsy to avoid serious dystrophy in the nail matrix?
A **3-mm** punch biopsy is the maximum size that does not produce serious dystrophy, although even this size can cause effects if performed in the most proximal portion of the nail matrix.
107
What technique is advised when longitudinal melanonychia is located in the lateral part of the nail plate?
The recommended technique is to use a lateral longitudinal biopsy.
108
What is the technique for diagnosing inflammatory disorders involving all subunits of the nail apparatus?
The lateral longitudinal biopsy is the best technique for diagnosing inflammatory disorders such as lichen planus or psoriasis.
109
What is the maximum size for a punch biopsy to avoid serious dystrophy in the nail matrix?
A 3-mm punch biopsy is the maximum size that does not produce serious dystrophy, although even this size can cause effects if performed in the most proximal portion of the nail matrix.
110
What technique is advised when longitudinal melanonychia is located in the lateral part of the nail plate?
A lateral longitudinal biopsy is advised when longitudinal melanonychia is in the lateral part of the nail plate.
111
What is the significance of the origin of longitudinal melanonychia in relation to nail dystrophy?
The more proximal the origin of longitudinal melanonychia, the greater the risk of nail dystrophy postoperatively.
112
What is the purpose of backstitches for the lateral nail folds during a biopsy?
Backstitches for the lateral nail folds help avoid their flattening, especially for thick toenails, and it is helpful to soak the nails in warm water before the procedure.
113
What is the technique used to remove the proximal third of the nail plate during a biopsy?
The technique involves making a circumferential incision around the origin of the band through the nail plate, followed by reflecting the proximal nail fold and removing the proximal third of the nail plate while leaving the cylinder of tissue containing the origin of the longitudinal melanonychia in place.
114
What is the recommended approach for a transverse biopsy of the nail matrix?
For a transverse biopsy, two small oblique incisions are made on each side of the proximal nail fold, and the fold is then reflected to expose the matrix area before avulsing the proximal third of the nail plate.
115
What is Haneke's releasing flap technique used for?
Haneke's releasing flap technique is used for longitudinal melanonychia located within the midportion of the nail plate, aiming to minimize postoperative dystrophy.
116
What is the clinical significance of establishing the matrix origin of longitudinal melanonychia preoperatively?
Establishing the matrix origin (proximal or distal) of longitudinal melanonychia is crucial because it influences the risk of postoperative nail dystrophy; the more proximal the origin, the greater the risk.
117
What is the advantage of using a tangential matrix biopsy for longitudinal melanonychia?
A tangential matrix biopsy is a good option for wide longitudinal melanonychia as it allows for effective removal of the pigmented lesion while minimizing trauma to surrounding tissues.
118
What is the role of a magnifying lens during the biopsy of the distal nail matrix?
The magnifying lens allows the surgeon to inspect the surrounding nail matrix and bed to determine whether the pigment extends around the punch incision.
119
What is the recommended method for excising a lesion during a transverse biopsy?
The lesion is removed by excising an elliptical or crescent-shaped wedge of tissue with the convex portion paralleling the anterior border of the lunula.
120
What is the purpose of reflecting the proximal nail fold during a biopsy?
Reflecting the proximal nail fold exposes the matrix area, allowing for better access to the lesion and minimizing trauma to the surrounding tissues.
121
What is the best cosmetic result technique for removing a pigmented lesion from the nail plate?
The technique involves cutting and reclining the proximal portion of the nail plate after reflecting the proximal nail fold, followed by tangential removal of the pigmented lesion and replacing the proximal nail plate.
122
What is the importance of soaking thick toenails in warm water before a biopsy?
Soaking thick toenails in warm water helps to soften the nail, making it easier to perform the biopsy and reducing the risk of trauma.
123
What is the recommended incision technique for a punch biopsy of the distal nail matrix?
A circumferential incision is made around the origin of the longitudinal melanonychia through the nail plate, ensuring access to the distal matrix.
124
What is the significance of using a full-thickness fragment of the matrix during a lateral longitudinal biopsy?
Using a full-thickness fragment of the matrix ensures that the biopsy captures all relevant tissue for accurate diagnosis and assessment of the lesion.
125
What is the role of the proximal nail fold in nail surgery?
The proximal nail fold serves as a critical anatomical landmark during nail surgery, and its preservation is important for minimizing postoperative complications.
126
What is the technique for ensuring the removal of the cylinder of biopsy tissue during a punch biopsy?
The technique involves using Gradle scissors to facilitate the removal of the cylinder of biopsy tissue after making the necessary incisions.
127
What is the clinical implication of performing a biopsy in the most proximal portion of the nail matrix?
Performing a biopsy in the most proximal portion of the nail matrix can lead to serious dystrophy, making it crucial to limit the size and location of the biopsy.
128
What is the purpose of using a magnifying lens during the inspection of the nail matrix?
The magnifying lens allows for detailed examination of the nail matrix to assess the extent of pigmentation and ensure accurate diagnosis.
129
What is the recommended approach for managing the proximal nail fold during a transverse biopsy?
The proximal nail fold should be reflected to expose the matrix area, and oblique incisions should be maintained to ensure proper healing and cosmetic results.
130
What is the significance of the lateral nail groove in the biopsy procedure?
The lateral nail groove is important as it serves as the starting point for incisions, ensuring that the biopsy includes the necessary tissue without causing excessive trauma.
131
What is the recommended technique for minimizing trauma during nail surgery?
Minimizing trauma involves separating all periungual attachments except for the connection between the dorsum of the nail and the ventral aspect of the proximal nail fold, followed by en bloc reflection of both.
132
What is the clinical significance of the proximal nail fold in relation to nail biopsies?
The proximal nail fold is crucial for determining the origin of lesions and ensuring that biopsies are performed with minimal impact on nail function and appearance.
133
What is the recommended technique for excising a lesion when longitudinal melanonychia is present?
When longitudinal melanonychia is present, an elliptical or crescent-shaped wedge of tissue should be excised, ensuring that the convex portion parallels the anterior border of the lunula.
134
What is the importance of the proximal nail fold in the context of nail surgery?
The proximal nail fold is important for maintaining the structural integrity of the nail unit and minimizing complications during and after nail surgery.
135
What is the technique for performing a nail bed biopsy?
A nail bed biopsy is performed using a 3- or 4-mm diameter punch driven perpendicularly into the nail plate in a circular motion down to the bone. A 6-mm punch can also be used to perforate the nail plate without injuring the underlying tissue. After detaching the covering nail with a scalpel, the biopsy is performed using a 4-mm punch to the bone, and the tissue is released with fine scissors. It is advisable to replace the 6-mm disk of nail keratin after cleaning with 10% hydrogen peroxide.
136
What are the primary approaches for nail matrix procedures?
The primary approaches for nail matrix procedures include: 1. Reduction in its width 2. Reduction in its length for tumor removal, using a cold steel procedure 3. A 2- to 3-mm punch biopsy. Complete matricectomy is rarely performed as it results in permanent loss of the nail.
137
In what circumstances is reduction of the nail matrix width necessary?
Reduction of the nail matrix width is necessary in the following circumstances: - Need for lateral-longitudinal biopsy - Lateral nail splitting - Benign or malignant tumor in the lateral third of the nail apparatus - Longitudinal melanonychia in a lateral location - Ingrown nail - Racquet nail.
138
What is the recommended technique for a tumor located in the lateral third of the nail?
For a tumor located in the lateral third of the nail, the recommended technique is a lateral longitudinal nail biopsy, which involves the removal of the lateral portion of the nail with the defect. This approach is especially important when the tumor is close to the lateral margin.
139
What is the procedure for excising distal matrix tumors?
For distal matrix tumors, excision is performed as a transverse biopsy, except for very superficial epithelial tumors or wide longitudinal melanonychia, which can be removed by tangential shave excision.
140
What is the recommended treatment for tumors located in the lateral third of the nail matrix?
Lateral longitudinal nail biopsy is the best method for tumors in the lateral third of the nail matrix.
141
What is the recommended treatment for tumors located underneath the nail matrix?
Incision should be done parallel to the anterior border of the lunula for tumors located underneath the nail matrix.
142
What is the recommended treatment for a nail matrix tumor located in the middle region?
The proximal nail fold should be carefully freed from the underlying nail plate, obliquely incised at both sides, and reflected to expose the matrix area.
143
What is the technique for performing a nail bed biopsy using a punch biopsy?
A nail bed biopsy is performed using a 3- or 4-mm diameter punch driven perpendicularly into the nail plate in a circular motion down to the bone. A 6-mm punch can also be used to perforate the nail plate without injuring the underlying tissue. After detaching the covering nail with a scalpel, the biopsy is performed using a 4-mm punch, and the tissue is released with fine scissors. It is advisable to replace the 6-mm disk of nail keratin after cleaning with 10% hydrogen peroxide.
144
What are the primary approaches to nail matrix procedures?
The primary approaches to nail matrix procedures include: 1. Reduction in its width 2. Reduction in its length for tumor removal, using a cold steel procedure 3. A 2- to 3-mm punch biopsy. Complete matricectomy is rarely performed as it results in permanent loss of the nail.
145
In what circumstances is reduction of the nail matrix width considered necessary?
Reduction of the nail matrix width is necessary in the following circumstances: - Need for lateral-longitudinal biopsy - Lateral nail splitting - Benign or malignant tumor in the lateral third of the nail apparatus - Longitudinal melanonychia in a lateral location - Ingrown nail - Racquet nail.
146
What is the recommended technique for a tumor located in the lateral third of the nail?
For a tumor located in the lateral third of the nail, the recommended technique is a lateral longitudinal nail biopsy, which involves the removal of the lateral portion of the nail with the defect.
147
What is the procedure for a proximal nail fold biopsy?
A proximal nail fold biopsy can be performed using a 2- to 3-mm punch for tumor biopsy. A blister may be completely removed by shave biopsy using half a razor blade. Additionally, excision of a 3-mm crescent-shaped tissue segment in the proximal region of the lateral nail folds may assist in evaluating collagen disease.
148
What are the indications for reducing the length of the nail matrix?
Reduction of the nail matrix length is necessary in limited cases such as: 1. To obtain a transverse elliptical biopsy specimen 2. To treat tumors that are 3 mm wide or larger 3. To thin thick nails in patients with dystrophic congenital and/or hereditary disorders.
149
What is the significance of using a 6-mm punch in nail bed biopsy?
The 6-mm punch is significant in nail bed biopsy as it allows for perforation of the nail plate without injuring the underlying tissue, facilitating the removal of the covering nail and aiding in the biopsy process.
150
What are the chemical methods for destroying the lateral horn of the nail matrix?
Chemical destruction of the lateral horn of the matrix can be performed using: - 88% phenol - 80% trichloroacetic acid - 10% sodium hydroxide. These methods are used for treating lateral tumors, nail splitting, ingrowing nails, or racquet nails.
151
How should an incision be made for tumors located underneath the nail matrix?
For tumors located underneath the matrix, the incision should be made parallel to the anterior border of the lunula.
152
What is the principle of nail ablation and when is it indicated?
Nail ablation is the definitive removal of the entire nail organ, including the hyponychium, nail bed, matrix, and lateral and proximal nail folds. It is rarely indicated except for the treatment of malignant tumors of the nail apparatus or in cases of excessively painful nails that have been treated multiple times without success.
153
What are the indications for matricectomy and its consequences?
Matricectomy involves the complete extirpation of the nail matrix, resulting in permanent nail loss. It is indicated when permanent nail matrix removal is necessary, and the procedure is less extensive if only the matrix is removed without the entire nail organ.
154
What is the recommended technique for excising the nail apparatus when histopathologic examination is needed?
Scalpel excision is strongly advocated whenever the surgical specimen needs histopathologic examination, ensuring that the entire portion of the involved nail apparatus is excised en bloc.
155
What is the procedure for managing a subungual hematoma?
When the hematoma is partial (less than 25% of the visible portion of the nail), it should be drained with a pointed scalpel or by hot paperclip cautery over the center of the dark spot to relieve pain.
156
What are the steps involved in nail bed surgery?
Nail bed surgery involves the following steps: 1. Perform biopsy, removal of tumors, or treatment of subungual hematoma. 2. If a larger nail bed fragment is needed, perform a fusiform biopsy after partial avulsion of the lateral half of the nail. 3. Undermine the nail bed after excision to facilitate reapproximation of both sides. 4. Use a suture needle on fragile subungual tissues. 5. Stitch the wound with 6-0 resorbable thread. 6. Make relaxing incisions at the most lateral margins of the nail bed if necessary.
157
What is the primary indication for nail ablation and what does it involve?
Nail ablation is primarily indicated for the treatment of malignant tumors of the nail apparatus. It involves the complete removal of the entire nail unit, including the hyponychium, nail bed, matrix, and lateral and proximal nail folds.
158
What is the significance of periungual pigmentation in relation to nail matrix excision?
If periungual pigmentation is associated with longitudinal melanonychia or if the pigmentation is wider than 6 mm, a large portion of the nail matrix would likely need to be excised, indicating that the underlying disease process is unlikely to be benign.
159
What are the preferred techniques for covering the defect after nail ablation?
The defect from nail ablation may be covered with a free graft (split-thickness, full-thickness, or reversed dermal graft) or a cross-finger flap. The use of skin from the intermediate phalanx of a neighboring finger is often more convenient for the patient.
160
What is the recommended approach for managing a subungual hematoma that is less than 25% of the visible portion of the nail?
When the hematoma is partial (less than 25% of the visible portion of the nail), it should be drained using a pointed scalpel or by hot paperclip cautery over the center of the dark spot to relieve pain.
161
What is the role of phenol cautery in matricectomy?
In cases where pathological examination of the removed tissue is unnecessary, phenol cautery is preferred over scalpel excision for matricectomy, as it is less extensive and effective for permanent nail matrix removal.
162
What are the key steps involved in nail bed surgery for biopsy?
Key steps in nail bed surgery for biopsy include: 1. Perform a fusiform biopsy with a major longitudinal axis after partial avulsion of the lateral half of the nail. 2. Undermine the nail bed to facilitate reapproximation of both sides. 3. Use a suture needle on fragile subungual tissues. 4. Stitch the wound with 6-0 resorbable thread. 5. Make relaxing incisions at the most lateral margins of the nail bed if necessary.
163
What is the clinical significance of a positive benzidine result in nail scrapings?
A positive benzidine result in nail scrapings indicates the presence of hemosiderin, which suggests that the blackish pigment observed may be due to bleeding or a hematoma rather than a benign condition.
164
What is the recommended management for a larger nail bed fragment needed during surgery?
If a larger nail bed fragment is needed, a fusiform biopsy can be performed after partial avulsion of the lateral half of the nail or after total avulsion if the fragment is central, ensuring proper reapproximation of the nail bed.
165
What are the potential outcomes of small hematomas included in the nail?
Small hematomas may be included in the nail but cannot be degraded to hemosiderin, and the results of the Prussian blue test will be negative, indicating that they do not represent significant bleeding.
166
What is the importance of histopathologic examination in nail surgery?
Histopathologic examination is crucial in nail surgery to ensure accurate diagnosis and treatment, particularly when excising lesions that may be malignant or when the underlying disease process is uncertain.
167
What is the significance of a hematoma involving more than 25% of the visible portion of the nail?
A hematoma involving more than 25% of the visible portion of the nail indicates a significant nail bed injury, and a radiograph is mandatory as the phalanx may be fractured.
168
What is the recommended approach for repairing nail bed defects larger than 4 mm?
Nail bed defects larger than 4 mm can be repaired using a split-thickness graft taken either from the nail bed of the same digit or from the nail bed of a great toe.
169
What are the main causes and symptoms of recalcitrant chronic paronychia?
The main cause of recalcitrant chronic paronychia is the presence of a foreign body (e.g., hair) under the proximal nail fold. Symptoms include painless red swelling, secondary retraction of the paronychial tissue, and recurrent episodes of acute paronychia inflammation.
170
What is the technique for crescentic excision in the treatment of chronic paronychia?
For crescentic excision, a Freer septum elevator is inserted under the proximal nail fold to protect the matrix and extensor tendon. A No. 15 Bard-Parker blade is then used to excise a crescent-shaped full-thickness skin segment, 4 mm at its greatest width, extending from one lateral nail fold to the other.
171
How should tumors of the proximal nail fold be excised?
Tumors of the proximal nail fold that are situated in a median position and have a longitudinal axis longer than 4 to 5 mm can be excised with a wedge of proximal nail fold whose base is located at the free margin and whose apex points proximally. Two relaxing lateral incisions are then made to allow suturing of the wedge-shaped defect after the undersurface of the proximal nail fold has been released from the nail plate.
172
What is the purpose of reconstructing the proximal nail fold?
Reconstruction of the proximal nail fold may be necessary after any injury (accident, burn, avulsion caused by rapidly rotating belts and sanders, etc.) to restore its structure and function.
173
What is the procedure for removing benign tumors from the lateral nail fold?
A 2- to 4-mm punch can be used to remove a tumor of the lateral nail fold. Benign tumors can also be removed by elliptical wedge of tissue from the lateral nail fold and lateral nail wall.
174
What is the primary cause of recalcitrant chronic paronychia?
The presence of a foreign body, such as hair, under the proximal nail fold is the main cause of recalcitrant chronic paronychia.
175
What is the recommended treatment for a subungual hematoma involving more than 25% of the visible nail?
A radiograph is mandatory to check for phalanx fractures, and the nail plate should be carefully removed to evacuate the hematoma.
176
What is the recommended treatment for chronic hematomas caused by repeated microtrauma?
Observation over a 3-week period is recommended to determine whether the nail grows independently of the pigmentation or with it.
177
What is the recommended treatment for tumors of the proximal nail fold with a longitudinal axis longer than 4-5 mm?
A wedge excision of the proximal nail fold is recommended, with two relaxing lateral incisions to allow suturing of the defect.
178
What is the recommended treatment for a nail bed defect larger than 4 mm?
A split-thickness graft taken from the nail bed of the same digit or the great toe can be used to repair the defect.
179
What is the significance of a hematoma involving more than 25% of the visible portion of the nail?
It indicates a significant nail bed injury, and a radiograph is mandatory to check for possible phalanx fractures.
180
What is the recommended approach for traumatic nail bed lacerations?
A surgical approach is necessary to avoid delayed complications, and the nail bed should be cleaned thoroughly before suturing.
181
How should a nail bed defect larger than 4 mm be repaired?
It can be repaired using a split-thickness graft taken from the nail bed of the same digit or from the nail bed of a great toe.
182
What is the procedure for managing chronic hematomas in the nail bed?
Chronic hematomas are usually painless and may resemble subungual melanoma; a notch is made with a scalpel at the borders of the pigmented spot, and observation over a 3-week period is necessary to determine nail growth.
183
What is the main cause of recalcitrant chronic paronychia?
The main cause is the presence of a foreign body, such as hair, under the proximal nail fold.
184
What is the technique for crescentic excision in chronic paronychia?
A Freer septum elevator is inserted under the proximal nail fold, and a crescent-shaped full-thickness skin segment is excised using a No. 15 Bard-Parker blade.
185
What are the considerations for excising tumors of the proximal nail fold?
Crescentic excision is useful for small distal tumors, and the crescent should not exceed 4 mm at its greatest width.
186
How are tumors of the proximal nail fold excised when they are larger than 4 to 5 mm?
They can be excised with a wedge of proximal nail fold, and two relaxing lateral incisions are made to allow for suturing of the wedge-shaped defect.
187
What is the purpose of reconstructing the proximal nail fold?
Reconstruction may be necessary after any injury, such as accidents or avulsions, to restore the normal appearance and function of the nail fold.
188
What technique can be used to restore the proximal nail fold after injury?
Two long, narrow, V-shaped transposition flaps from the lateral aspects of the terminal phalanx can be used for restoration.
189
What is the procedure for removing a tumor from the lateral nail fold?
A 2- to 4-mm punch can be used to remove the tumor, and benign tumors can be removed by an elliptical wedge of tissue from the lateral nail fold and wall.
190
What is the clinical significance of a chronic hematoma in the nail bed?
It may resemble subungual melanoma and should be differentiated from nonmigrating hematomas to avoid misdiagnosis.
191
What is the recommended suture technique for a torn nail bed?
The torn nail bed should be sutured with 6-0 resorbable thread, taking large bites of tissue to prevent the suture material from pulling through.
192
What is the role of the proximal nail fold in nail health?
The proximal nail fold is responsible for the normal shine of the nail plate and protects the nail matrix.
193
What is the approach for managing repeated acute flares in chronic paronychia?
Additional removal of the base of the nail may be necessary to manage repeated acute flares effectively.
194
How can the healing of secondary defects in the proximal nail fold be improved?
Healing can be improved by making a relaxing crescent-shaped incision in the proximal nail fold in addition to the relaxing lateral incisions.
195
What is the importance of observing a pigmented spot in the nail bed over a 3-week period?
Observation helps determine whether the nail grows independently of the pigmentation or with it, which is crucial for diagnosis.
196
What is the technique for raising a dorsal flap from the proximal nail fold?
Two dorsolateral incisions and a horizontal incision proximal to the cuticle are made to raise a dorsal flap for exposure of subcutaneous tumors.
197
What is the potential drawback of crescentic excision in chronic paronychia?
The proximal nail fold may be slightly retracted, leading to a longer nail, which can be avoided by reclining the PNF during the procedure.
198
What is the significance of using a beveled incision during crescentic excision?
A beveled incision prevents accidental damage to the proximal nail matrix and the most proximal portion of the proximal nail fold.
199
What is the clinical approach for a nail bed laceration after thorough cleaning?
The nail plate should be put back to cover the wound and secured by suturing to the lateral nail folds or the fingertip.
200
What is the expected healing process for symmetric narrow defects after excision in the proximal nail fold?
These defects heal rapidly by secondary intention, which is a natural healing process.
201
What is the role of a radiograph in the assessment of nail injuries?
A radiograph is mandatory to assess for possible fractures of the phalanx in cases of significant nail bed injury.
202
What is the procedure for managing a small tumor on the lateral part of the proximal nail fold?
It may be treated using a wedge-shaped excision, with only one lateral relaxing incision made at the opposite region of the proximal nail fold.
203
What is the importance of using 6-0 resorbable monofilament material for suturing nail bed lacerations?
This material is preferred for its absorbable properties, minimizing the need for suture removal and reducing patient discomfort.
204
What is the expected outcome of reconstructing the proximal nail fold after injury?
The reconstruction aims to recreate the distal curve of the proximal nail fold, producing a nearly perfect restoration of its function and appearance.
205
What is the significance of the nail plate in the management of nail bed injuries?
The nail plate serves as a protective cover for the wound and is crucial for proper healing when sutured back in place.
206
What is the recommended follow-up for patients with chronic hematomas in the nail bed?
Patients should be observed over a 3-week period to monitor nail growth and assess for any changes in pigmentation.
207
What is the technique for excising irregular tissue in the proximal nail fold?
If irregular tissue is excised, it may be possible to recreate the distal curve of the proximal nail fold for restoration.
208
What is the clinical approach for a nail bed defect that is larger than 4 mm?
A split-thickness graft should be used to repair the defect, ensuring proper healing and restoration of nail bed integrity.
209
What is the role of the lateral nail fold in nail health?
The lateral nail fold provides protection to the nail matrix and contributes to the overall health and appearance of the nail.
210
What is the primary cause of ingrown nails and how is it treated?
Ingrown nails occur mainly in the great toe due to the impingement of the nail plate into the dermal tissue distally or into the distolateral nail groove. Treatment typically involves correcting the disparity by surgical methods such as excision of the offending nail portion.
211
What is the characteristic triad of retronychia?
The characteristic triad of retronychia includes: 1. Disruption of linear nail growth 2. Subacute paronychia 3. Lifting at the rear of the nail due to a double or triple-layered proximal nail plate associated with frequent xanthonychia.
212
What are the steps involved in the surgical treatment of juvenile (subcutaneous) ingrown nails?
The surgical treatment of juvenile ingrown nails involves the following steps: 1. The lateral fifth of the nail plate is freed from the proximal nail fold and subungual tissues. 2. The nail is cut longitudinally with nail-splitting scissors and extracted using a sturdy hemostat. 3. The lateral matrix horn is cauterized with a freshly made solution of liquefied phenol (88%). 4. Hemostasis is achieved using a tourniquet, and the area is cleaned with sterile gauze.
213
What is the treatment approach for distal toenail embedding?
The treatment for distal toenail embedding involves crescentic wedge-shaped excision made around the distal phalanx. The wedge should be 4 mm at its greatest width and must be dissected from the bone. The defect is then closed with 5-0 monofilament sutures, which should be removed after 12 to 14 days.
214
What is the characteristic triad of retronychia?
The triad includes disruption of linear nail growth, subacute paronychia, and lifting at the rear of the nail due to a double or triple-layered proximal nail plate.
215
What is the pathognomonic ultrasound sign of retronychia?
The pathognomonic sign is the shortening of the distance between the proximal edge of the nail and the distal interphalangeal joint.
216
What is the recommended treatment for a juvenile ingrown nail with excessive granulation tissue?
Definitive treatment involves surgical excision or chemical suppression of the lateral horn of the nail matrix using phenol cautery.
217
What is the primary goal of crescentic wedge-shaped excision in distal toenail embedding?
The goal is to remove hypertrophic distal subungual tissues and prevent the newly formed nail plate from abutting the distal wall.
218
What is the recommended treatment for benign tumors of the lateral nail fold?
Benign tumors can be removed by elliptical wedge excision from the lateral nail fold and lateral nail wall.
219
What is the recommended treatment for malignant tumors of the lateral nail fold?
Malignant tumors, such as in Bowen disease, require excision of the whole lateral nail fold or Mohs micrographic surgery.
220
What is the primary treatment for ingrown nails caused by impingement of the nail plate into the dermal tissue?
The logical treatment for ingrown nails is aimed at correcting the disparity between the nail bed and the nail plate, often involving surgical intervention to relieve pressure and remove the offending tissue.
221
What is the recommended surgical treatment for distal toenail embedding?
The recommended surgical treatment is a crescentic wedge-shaped excision made around the distal phalanx, with the defect closed using 5-0 monofilament sutures, which should be removed after 12 to 14 days.
222
What are the characteristic features of retronychia?
Retronychia is characterized by proximal regrowth of the nail into the proximal nail fold, thickening of the proximal portion of the nail plate, painful paronychia, and disruption of linear nail growth, often accompanied by proximal granulation tissue and inflammatory subungual exudate.
223
What is the initial conservative treatment for juvenile (subcutaneous) ingrown nails?
The initial conservative treatment involves soaking the foot in warm water with povidone-iodine soap, followed by the removal of the nail spicule under local anesthesia and placing a wisp of cotton wool between the nail and the lateral nail groove to keep it moist with disinfectant.
224
What is the definitive surgical treatment for juvenile ingrown nails?
The definitive surgical treatment involves excising the lateral horn of the nail matrix to permanently narrow the nail, which includes freeing the lateral fifth of the nail plate and cauterizing the lateral matrix horn with liquefied phenol.
225
What is the pathognomonic sign of retronychia observed through ultrasound?
The pathognomonic sign of retronychia observed through ultrasound is the shortening of the distance between the proximal edge of the nail and the distal interphalangeal joint.
226
What are the common complications associated with juvenile ingrown nails if left untreated?
If left untreated, juvenile ingrown nails can lead to secondary infections, excessive granulation tissue, and chronic pain due to the nail spicule piercing the epithelium of the lateral nail groove.
227
What is the significance of using a bloodless field during the surgical treatment of ingrown nails?
A bloodless field is crucial during the surgical treatment of ingrown nails because blood inactivates phenol, which is used for cauterization of the nail matrix.
228
What is the typical healing time for wounds after surgical treatment of ingrown nails?
The wound typically heals within 2 weeks without prolonged exudative discharge following surgical treatment of ingrown nails.
229
What is the role of daily warm foot baths in the postoperative care of ingrown nails?
Daily warm foot baths with povidone-iodine soap are recommended to accelerate healing and maintain cleanliness in the postoperative care of ingrown nails.
230
What is the typical presentation of congenital malalignment of the great toenail?
The nail is malaligned laterally, often with transverse furrows on a thick brownish or greenish nail. In 50% of cases, this condition corrects itself without therapy before the age of 10.
231
What is the primary treatment for pincer nail condition?
The primary treatment involves the nail brace technique, which corrects the inward distortion of the nail by maintaining continuous tension on the nail plate. A definitive cure can be achieved using phenol cautery on the lateral matrix horn.
232
What surgical technique is used for treating hypertrophy of the lateral nail fold?
The treatment involves removing approximately one-fifth of the nail that digs into the lateral nail fold, followed by taking an elliptical wedge of tissue from the lateral nail wall down to the bone, and suturing the defect to pull the lateral nail fold away from the offending edge.
233
What noninvasive treatments are effective for ingrown nails?
Effective noninvasive treatments include anchor taping and acrylic affixed gutter splint methods, which provide good results, especially in children, and do not require invasive surgery.
234
What is the significance of the matrix origin in longitudinal melanonychia?
The more distal the matrix origin of longitudinal melanonychia, the greater the risk of nail dystrophy.
235
What is the recommended treatment for pincer nails causing severe pain?
Phenol cautery on the lateral matrix horn is the simplest and most effective treatment for pincer nails.
236
What is the primary cause of hypertrophy of the lateral nail fold?
Hypertrophy of the lateral nail fold is usually caused by long-standing ingrown nails.
237
What is the recommended treatment for congenital malalignment of the great toenail?
Surgical rotation of a bulky nail unit flap, including the entire nail, nail bed, and matrix, is recommended for extreme cases.
238
What is the preferred noninvasive treatment for ingrown nails in children?
Anchor taping and acrylic affixed gutter splint methods are effective noninvasive treatments for ingrown nails in children.
239
What is the primary treatment for congenital malalignment of the great toenail when surgery is indicated?
The primary treatment involves the rotation of a bulky nail unit flap, including the entire nail, nail bed, and matrix, which requires the creation of an external Burrow's triangle.
240
What is the definitive cure for pincer nail condition?
The definitive cure for pincer nail is the use of phenol cautery on the lateral matrix horn, which is the simplest effective treatment modality.
241
What is the typical outcome for congenital malalignment of the great toenail in children under the age of 10?
In 50% of cases, congenital malalignment of the great toenail corrects itself without therapy before the age of 10.
242
What is the recommended treatment for hypertrophy of the lateral nail fold due to long-standing ingrown nails?
The treatment involves removing approximately one-fifth of the nail that is digging into the lateral nail fold and taking an elliptical wedge of tissue from the lateral nail wall down to the bone.
243
What noninvasive methods are effective for treating ingrown nails, especially in children?
Effective noninvasive methods include anchor taping and acrylic affixed gutter splint techniques, which do not require invasive surgery.
244
What is the significance of the crescent-shaped excision in the treatment of congenital malalignment of the great toenail?
The crescent-shaped excision is significant as it undermines the nail unit, allowing for proper redirection of the nail and reducing the risk of permanent dystrophy.
245
What is the common complication associated with untreated pincer nail conditions?
The common complication is relapse, as the underlying bone pathology remains untreated despite correction of the nail curvature.
246
What is the relationship between the matrix origin of longitudinal melanonychia and the risk of nail dystrophy?
The more distal the matrix origin of longitudinal melanonychia, the greater the risk of nail dystrophy.
247
What is the role of suturing in the treatment of hypertrophy of the lateral nail fold?
Suturing pulls the lateral nail fold away from the offending lateral nail edge, helping to alleviate the condition.
248
What is the expected outcome for congenital lateral hypertrophic lips in children?
Congenital lateral hypertrophic lips typically disappear progressively and spontaneously within 12 months.
