Nail surgery

Question 1

e. Precautions of surgery

Answer 1

 Thorough medical history, including medications and allergies.
 Neurovascular Assessment.
 Diabetes1,2
 Regular BSLs leading up to procedure if concerned about diabetic control.
 PVD/PAD3
 Vascular studies should be conducted if concerned of circulation.
 ABI’s and toe pressures (PPG) – may need to refer to GP.
 Normal ABI 0.9>1.29
 Normal TBI 0.8, concern is <0.5
 Immunosuppressant use
 Anticoagulation use
 Current infection
 Smoker?
 Pregnancy?

Question 2

• Considerations of nail surgery

Answer 2

• Why is the nail painful?
• Current infection/ incidence of infection.
• Where is the nail painful?
• What (if any) other structures are involved?
• When is the nail painful?
• Gross infection – refer patient for antibiotics
• Minor localised infection.
• Consider nail wedge resection
• Don’t delay surgery if patient is in pain.

Question 3

pre op care

Answer 3

• Gain written informed consent
• Discuss with patient what the procedure involves as well as post operative outcomes
• Discuss regrowth rate, risk of infection and risk of phenol burn.
• Discuss post operative patient requirements, including appropriate footwear, dressings, pain relief and to monitor for any sign of infection.
• Provide patient with written information sheet prior to procedure.

Question 4

precautions

Answer 4

a. Allergy
b. Infection
c. Renal/hepatic impairment (increased risk of toxicity with repeated administration).
d. Anticoagulated patients
e. Elderly
i. Hypersensitive, reduce dose.
f. Considered safe during pregnancy and breast feeding.

Question 5

b. Difference between 1% and 2%

Answer 5

4. 1% lignocaine for phenol procedure
5. 2% lignocaine for avulsion with chronic infection as low pH of tissues deactivates

Question 6

surgery instruments

Answer 6

• 1 periosteal elevator
• 1 pair nail splitters
• 1 beaver handle – disassembled - or fixed beaver
• 1 double ended curette
• 1 mosquito forceps
• 1 Kelly or similar forceps - may be packed separately
• 1 scalpel handle number 3
• 1 scissors
• ## 1 Tornicot green/blue

Question 7

a. Photo of IGTN- red/ pus, what you’d do rx for today/ and long term

Answer 7

• refer to GP for antibiotics- suspected infection cannot operate.
  once infection settles partial nail avulsion

Question 8

a. Flucloxacillin
indications and concern

Answer 8

Indications:
* Staphylococcal skin infections
* Osteomyelitis, septic arthritis
- hepatotoxic

Question 9

plantar plate grading

Answer 9

stage 1:
mild plantar pain and oedema to MTPJ
Tenderness with manipulation of joint
No malalignment

stage 2:
deviatation of toe clinically
stance: ‘just’ not purchasing
positive stress test

stage 3:
moderate oedema around whole MTPJ
subluxation and dislocation, cross over toe
base in. fixed dislocation