44: Nail Surgery - Mahoney Flashcards Preview

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Flashcards in 44: Nail Surgery - Mahoney Deck (19)
1

review nail anatomy

2

matrix vs. nail bed

•Matrix-epithelium overlying nail bed dermis that extends over the base of the distal phalanx to the distal edge of the lunula

•Nail bed-everything distal to the lunula and does not produce any portion of the nail plate-includes a thin layer of keratin that assures firm attachment with nail and, at same time, allows it to slide over bed

3

The nail pocket or space is sealed proximally by the cuticle and distally by the ...

hyponychium

 

4

what forms the cuticle?

Cuticle-formed by the free margin of the posterior nail fold, and mostly, from the horny layer of the eponychium

5

80% of nail produced by  _____ half of matrix

proximal

activity is higher in proximal portion   so nail is naturally curved in convex   shape from proximal to distal

matrix = convex band of highly proliferative epithelium

6

how should you direct an incisional biopsy of the matrix?

Due to the arrangement of the matrix from proximal to distal, always take an incisional biopsy of the bed with the long axis of the incision parallel to the long axis of the nail to avoid minimal damage to the matrix and future nail growth

7

which is true?

the matrix of the nail ...

1.Covers the entire surface of the nail bed

2.Extends over the base of the distal phalanx to the lunula

3.Along with the nail bed, produces the nail plate

4.Is most active under the lunula

5.Nail bed biopsies should be oriented transversly

2

8

describe DuVries surgery

  • Remove large section of skin (without nail) from the side of the toe with two semi-elliptical incisions closed with stitches
  • Designed to relieve all of soft tissue pressure from side of in-growing toenail

9

describe partial and total nail avulsion

•Usually reserved for first-time nail removal

•Nail will re-grow, often with a change in shape [Offending portion of nail removed, but matrix left intact]

•Usually reserved for paronychias, subungual hematomas, partial traumatic nail avulsions

 

10

define a partial matrixectomy

Matrix is permanently removed along medial and/or lateral borders with corresponding overlying nail plate

Total matrixectomy = Entire nail matrix is removed with entire toenail

11

describe phenol and alcohol matrixectomy technique

  1. Nail is removed with nail splitter
  2. Matrix is curetted
  3. Skin protected by Vaseline
  4. Phenol (88% carbolic acid) applied to matrix by Q-tip in 3, 30 second applications
  5. Phenol neutralized (?) by 70% isopropyl (rubbing) alcohol (more likely irrigation)

do same thing with 10% NaOH and 5% acetic acid

changes for total nail PA: Nail removed in its entirety by utilizing mosquito hemostat to free up dorsal nail fold and separate nail plate from nail bed; Utilize chemicals for 3, 45 second applications

Picture of total nail matrixectomy:

 

 

12

post-op care for P&A

  • Apply dressing with Silvadene (*sulfa allergies*), gauze, Kling
  • Keep dry and intact until following a.m.
  • Soak 5 minutes in warm, soapy water bid, followed by 2 drops of Cortisporin Otic Suspension® (Neomycin, Polymyxin B, 1% Hydrocortisone) and bandaid or gauze.
  • Air dry as much as possible when in a clean environment
  • Avoid enclosed shoes for 1 week
  • Follow in 1 week
  • After 1 week, d/c soaks and ear drops
  • Apply betadine solution or Bactine® bid for 3-7 days
  • Return to enclosed shoes
  • Opinion: Avoid use of ointments or creams after initial dressing

13

describe winograd method of matrixectomy

  • Wedge of skin and nail plate removed down through matrix to bone with scalpel
  • One incision longitudinal through nail, second converging incision through soft tissue along nail border
  • Bone is rasped
  • Incision closed with sutures

14

describe Frost technique for matrixectomy

  • One longitudinal incision through nail plate extending from tip to skin proximal to nail plate
  • Second incision at right angle to first extending away from nail plate at base of first incision
  • Reflect back flap
  • Remove nail plate and matrix down to bone
  • Rasp bone
  • Suture wound closed

15

osteotripsy

utilizes high-speed rotating burr to remove matrix down to bone

16

describe zadik/quenu technique

  • Nail plate removed
  • “H”-shaped incision made with connecting incision placed proximal to the eponychium
  • Proximal skin reflected and matrix beneath is excised to bone
  • Proximal and distal flaps sutured together

17

describe terminal syme procedure for nail removal

*** not used unless everything else has failed

  • Remove nail plate and matrix down to bone with circumferential incision around nail plate
  • Remove distal 1/3 of distal phalanx to create less tension for closure
  • Suture utilizing plantar flap which advances dorsally to meet proximal incision
  • Post op: treat same as any incisional surgery, keep toe dry for 1 wk, after 1 wk dress daily with betadine solution and gauze, use surgical shoe until stitches removed (2wk)

18

which procedures do not involve removing or rasping bone?

1.Du Vries

2.Winograd

3.Frost

4.Phenol and alcohol

5.Terminal Syme

1 and 4

19

The nail surgery that involves an “L” shaped incision along the nail border through the nail plate is called:

frost

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