44: Nail Surgery - Mahoney

Question 1

review nail anatomy

Answer 1

Question 2

matrix vs. nail bed

Answer 2

•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

Question 3

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

Answer 3

hyponychium

Question 4

what forms the cuticle?

Answer 4

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

Question 5

80% of nail produced by _____ half of matrix

Answer 5

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

Question 6

how should you direct an incisional biopsy of the matrix?

Answer 6

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

Question 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

Answer 7

2

Question 8

describe DuVries surgery

Answer 8

• 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

Question 9

describe partial and total nail avulsion

Answer 9

• 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

Question 10

define a partial matrixectomy

Answer 10

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

Question 11

describe phenol and alcohol matrixectomy technique

Answer 11

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:

Question 12

post-op care for P&A

Answer 12

• 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

Question 13

describe winograd method of matrixectomy

Answer 13

• 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

Question 14

describe Frost technique for matrixectomy

Answer 14

• 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

Question 15

osteotripsy

Answer 15

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

Question 16

describe zadik/quenu technique

Answer 16

• 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

Question 17

describe terminal syme procedure for nail removal

*** not used unless everything else has failed

Answer 17

• 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)

Question 18

which procedures do not involve removing or rasping bone?

1. Du Vries
2. Winograd
3. Frost
4. Phenol and alcohol
5. Terminal Syme

Answer 18

1 and 4

Question 19

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

Answer 19

frost