Bologna CH149 Nail Surg

Question 1

The nail bed, aka the sterile matrix, extends from the distal lanula to the hyponychium

Answer 1

True

Question 2

A rich vascular supply leads to the pink colour that is visible through the translucent nail plate

Answer 2

True

Question 3

Surgery of the nail bed commonly leads to nail dystrophy

Answer 3

False rare

Question 4

Surgery of the nail bed may result in mild onycholysis

Answer 4

True

Question 5

Hyponychium is where the nail plate detaches to form its free edge

Answer 5

True

Question 6

Disruption of the hyponychium by trauma or disease can result in onycholysis , followed by bacterial and fungal contamination

Answer 6

True

Question 7

Proximal nail fold protects most of the matrix and newly formed plate

Answer 7

True

Question 8

The perionychium is the paronychium + hyponychium + nail matrix

Answer 8

False - nail bed not nail matrix

Question 9

The index, middle and ring fingertips are innervated by the dorsal digital nerves whilst the thumb and little finger are innervated by the palmar nerves

Answer 9

False — 2, 3, 4 innervated by palmar and 1 , 5 innervated by dorsal

Question 10

Paired proper digital arteries run along the lateral and volar sides of the digit

Answer 10

True

Question 11

Nail nippers are essential for cutting the nail plate

Answer 11

True

Question 12

Nail surgery does not require a bloodless surgical field

Answer 12

False

Question 13

Tourniquet for the digit can be applied for a maximum of 30 min

Answer 13

True

Question 14

Steps in Removal of glomus tumour

Answer 14

• written procedural , financial consent
• discuss risks: bleed, infection, scarring, nail dystrophy, compartment syndrome, digital ischaemia
• digital ring and wing block with tourniquet application , start timer
• sterile field
• two oblique incisions at junction of the lateral and proximal nail folds,
• retraction of the proximal nail fold
• lateral AVULSION of the plate
• visualise tumour in nail matrix and excise
• replace proximal nail fold and insert sutures 4-0 silk
• pressure dressing and splint
• close follow up with review of wound and remove sutures in 10 days

Question 15

Within the nail bed, the incision should be oriented horizontally, whereas within the matrix it should be oriented longitudinally

Answer 15

False
Nail bed incision longitudinal
Matrix excision horizontal

Question 16

Nail bed bx has one major indication - determination of the cause of longitudinal melanonychia

Answer 16

True

Question 17

If pigment origin has longitudinal orientation, narrow elliptical ellipse down to bone is recommended

Answer 17

True

Question 18

Lateral longitudinal nail biopsy narrows the nail permanently due to complete amputation of the lateral matrix horn

Answer 18

False partial amputation

Question 19

Chronic paronychia that is recalcitrant may be treated with en bloc excision of proximal nail fold , from one lateral nail fold to the other

Answer 19

True

Question 20

What are the two major surgical approaches for an ingrown toenail

Answer 20

1 - narrow the nail plate via lateral matricectomy via chemical cautery phenol 88%
2 - debulking surrounding soft tissues

Question 21

Phenol has 3 relevant properties - necrotising, disinfecting and absorptive

Answer 21

False , anaesthetic rather than absorptive

Question 22

Phenol induces a very uncomfortable post op period

Answer 22

False - very comfortable as it induces demyelination of terminal nerve endings for several weeks

Question 23

How to perform a lateral longitudinal matricectomy

Answer 23

After anaesthesia established, place tourniquet to ensure completely bloodless field
- curette any granulation tissue for a better view of the lateral part of the nail plate
- avulse lateral or bilateral strip of nail plate 3-5mm in width up to its origin under the proximal nail fold
- phenol 88% is applied onto the exposed lateral horn of the matrix and bed with a wisp of cotton wool/urethral swab or elevator itself
—> do not oversoak cotton as may result in cauterant spilling onto periungal tissue
- ideal application time is 2-3 min

Question 24

Rinsing with alcohol can neutralise phenol

Answer 24

False, only dilutes it

Question 25

Phenol is unsafe in diabetics and children

Answer 25

False, safe

Question 26

Phenol is unhelpful in recaltricant ingrown toenails from EGFR inhibitors

Answer 26

False, it is helpful