Nail Deformities Flashcards
1
Q
What is Onychauxis?
A
- Pronounced ‘ony-coxicks’
- Clinical Abbreviation = OX
- hypertrophied nail
- uniform thickening (all across the nail plate)
2
Q
What are clinical features of OX?
A
- Uniform thickening across the nail
- Can be discoloured - yellow/brownish
- Because of thickness, may not be abel to see vascularised nail bed underneath the plate
- sulci often enlarged as a result of OX
3
Q
What is the Aetiology of OX?
A
- Damage to the nail matrix
- Trauma
- Shallow toe box
- Fungal infection
- Poor peripheral circulation
- Age related
- Psoriasis
- Digital deformity
4
Q
What is the pathology of OX?
A
- Changes to the nail matrix is the main cause of the hypertrophy
- Keratinocytes/Onychocytes grow upwards rather than forwards
5
Q
What is the treatment of OX?
A
- Cut + file nails
- reduce thickness using nail burr/drill
- remove debris (OP) with blacks file
- Footwear appraisal - stitching in footwear is normally double the thickness of the material and is not flexible, meaning the foot has to conform to its shape.
6
Q
What is Onychogryphosis?
A
- Clinical abbreviation = OG
- Classed as hypertrophy of the nail with deformity
- Also known as ‘Rams Horn’ deformity
7
Q
What are clinical features of OG?
A
- Transversal ridged surface of nail plate
- Enlarged/inflamed sulci
- Nail grey/yellow/brownish
- Hypertrophy of nail plate
- Curvature of nail plate to the side
8
Q
What is the aetiology of OG?
A
- Major trauma - often single heavy blow
- Repeated minor trauma - e.g ill fitting shoes
- Secondary to an infection
- Impaired blood supply
- Epidermal dyplasias
9
Q
What is the pathology of OG?
A
- Neglect of the free edge of the nail can result in increased intermittent compression to the nail and therefore can damage part of the nail matrix
- Proximal nail fold can retract meaning there is no uniform shape to the nail plate and it does not extend straight across the nail bed
- The part of the nail matrix which has been damaged grows slower and produces less onychocytes than the undamaged part of the matrix, resulting in the curvature
10
Q
What is the treatment of OG?
A
- Reduce the thickness with a nail drill
- Clear OP from sulci with blacks file
- Cut and file nail
- Patient advice
- Nail Avulsion
- Surgical option - total nail avulsion with chemical destruction of the nail matrix, if the patient is suitable
- Conservative option - 40% urea cream, applied biweekly.
- Urea is a keratolytic, allows hydration of the nail plate and maceration of the nail plate, enabling it to be debrided
11
Q
What is Onychophosis?
A
- Clinical Abbreviation = OP
- Debris in the sulci, lateral nail folds
12
Q
What are clinical features of OP
A
- Debris to sulci - Dry + Hard / Soft + Moist
- Subungal corn / callus
- Can result in localised inflammation and pain
13
Q
What is the aetiology of OP?
A
- Poor nail cutting technique
- Pressure from footwear
- Excessive pronation - rubbing and shearing of hallux both medially and laterally
- Pressure from adjacent toes
- Atrophic skin
14
Q
What is the pathology of OP?
A
- Lateral pressure to the toe nail
- Inflammation of the nail sulci
- Inflammation of the epithelium
15
Q
What is the treatment of OP?
A
- Removal of soft debris with blacks file
- Callus debridement, corn enucleation
- Nail may need to be cut to expose OP
- File with blacks file to limit trauma
16
Q
What is Onychomychosis?
A
- Clinical Abbreviation = OM
- Fungal nail infection of the toes, can also affect fingernails
- Can involve any component of the nail (Matrix, Plate, Bed)
- Generally not painful, however thickened nails can sometimes press into sulci
- About 3% of UK population may have OM, thought to be increasing due to aging population
- Diabetes patients more susceptible to getting it
17
Q
What are the four different clinical presentations of OM?
A
- Distal Subungal (DSO)
- White Superficial (WSO)
- Proximal Subungal (PSO)
- Candida Onychomychosis
18
Q
What is Distal Subungal Onychomychosis?
A
- Clinical Abbreviation = DSO (or DLSO if lateral as well)
- Most common form of OM
- Initially affect the hyponychium and lateral edges of nail, then spreads across the nail bed
- Associated with Onychauxis, Onychophosis, Onycholysis
- Typically caused by T.rubrum, but could also be T.mentagrophytes, T.tonsurans and E.floccosum
19
Q
What are Dermatophytes?
A
- Fungi that require keratin for growth
20
Q
What is Proximal Subungal Onychomychosis?
A
- Clinical Abbreviation = PSO
- Relatively uncommon
- Organisms invade the nail plate via the proximal nail fold
- Can look similar to Leukonychia
- Caused by T.rubrum, T.megninii, and E.floccosum
- Considered an early clinical marker of HIV
21
Q
What is White Superficial Onychomychosis?
A
- Clinical Abbreviation = WSO
- Occurs when there is bacterial invasion of the superficial layers of the nail plate directly
- Presence of opaque ‘white islands’
- Nail can become soft, rough and crumbly
- Caused by T.mentagrophytyes
*
22
Q
What is the aetiology of OM?
A
- Occurs more frequently in hallux nail plate
- occurs usually distally to nail matrix
- Micro trauma - break in the nail surface
- Poor foot hygiene
- Immunosuppression is a factor
- Occlusive footwear - moisture not wicked away from the skin
- Moist warm environment for fungal growth
23
Q
What is the pathology of OM?
A
- Crack in the nail
- Dermatophytes replicate in this area
- Dermatophytes can metabolise keratin
- Nail plate is colonized, feed on keratin, dissolved with enzyme meaning nail is destroyed
- Common dermatophytes:
- Tricophytum rubrum
- Tricophytum interdigitale
- Tricophyton mentagrophytes
- Epidermphyton flocossum
- Candida Albicans
24
Q
How can you diagose OM?
A
- Nail sample can be taken off to confirm presence of Fungal elements
- need to utilise clinical knowledge before this step is taken
25
Q
How do you treat OM?
A
- Reduction of thickness with drill
- Remove any OP
- Oral and topical treatments are availbale
- In extreme cases, where oral treatments not avialable - nail surgery
- Laser
- Phototherapy
- Nail avulsion
26
Q
What is Paronychia?
A
- Inflammation of the tissue surrounding the nail plate
- Frequently occurs alongside Onychia
27
Q
What are clinical features of Paronychia?
A
- Inflammatory signs
- Localised erythema
- Paim
- Warm
- Acute or Chronic
28
Q
What is the aetiology of Paronychia?
A
- Foreign body
- Bacteria
- Manifestation of systemic disease
- Local trauma
29
Q
What is the pathology of Paronychia?
A
- Localised inflammatory response
- Acute - appears suddenly after trauma
- Chronic - develops slowly, usually caused by fungal infections
30
Q
How should you assess Paronychia?
A
- Should be regarded as potentially serious
- Assess level of infection:
- How far away do signs of infection spread from area?
- Does patient present with any systemic signs?
- Promote draining of purulent exudate (pus)
- Swap, if clinically indicated to:
- Identify infecting organism to…
- Identify effective antibiotics
31
Q
What is the treatment of Paronychia?
A
- Use a dressing pack
- Sterile dressing & aseptic technique
- Educate patient on:
- Signs of clinical infection and indicators of worsening
- dressing regime
- return period
- Referral if high risk patient
32
Q
What is Onychia?
A
- Inflammation of nail bed and nail matrix
- Same as Paronychia, except area of inflammation
33
Q
What is Subungal Haematoma?
A
- Collection of blood underneath the nail plate
34
Q
What are the clinical characteristics of Subungal Haematoma?
A
- Initially red underneath the nail plate - turns black once the blood is coagulated
- Patient will usually report incident of trauma
- Can be very painful for patient
- Possible localised inflammation around the area of trauma
35
Q
What is the pathology of Subungal Haematoma?
A
- Trauma results in rupturing of nail vessels, resulting in bleeding into the nail plate
- Due to trauma Proximal Nail Fold (PNF) may also rupture, causing entry to bacteria
36
Q
What is the treatment of Subungal Haematoma? (acute)
A
- Drill the distal edge of the haematoma using a fine burr attachment
- this releases extruded blood an pressure, relieving pain
- Irrigate and dress the area
37
Q
What is the treatment of Subungal Haematoma? (chronic)
A
- If blood has coagulated / painful:
- Use anti inflammatory device
- Padding/dressing to offload pressure
- If not painful - monitor
- Check for Onycholysis / OX
- Patient advice
38
Q
What are Single Longitudinal Ridges / Myxoid Cyst?
A
- Benign tumours / Myxoid cysts / warts in the proximal nail fold may exert pressure of the nail fold causing longitudinal groove
39
Q
What is Onycholysis?
A
- Progressive seperation of the nail plate from the nail bed - distal to proximal
40
Q
What is the aetiology of Onycholysis?
A
- Systemic - poor peripheral circulation, iron deficiency anaemia, thyrotoxicotis
- Psoriasis, Eczema
- Hyperhidrosis
- Trauma - repetitive minor injury, toe deformity, long nails, shallow/short footwear
41
Q
What is the treatment of Onycholysis?
A
- Seperation from nail bed is uaually asymptomatic as free end quickly becomes filled with keratinous material and debris
- Due to location, rarely becomes infected
- Keep nail short - to prevent recurrence of trauma elevating incident
42
Q
What is Subungal Exostosis?
A
- Small outgrowth of bone under nail plate, near to the free edge
43
Q
What are clinical characteristics of Subungal Exostosis?
A
- Cherry red area underneath nail plate
- Depending on the location of the exostosis, the nail plate may lift from the bed
- Extreme pain when pressure applied to area
- Generally speaking occur on the Hallux
44
Q
What is the aetiology of Subungal Exostosis?
A
- Currently unknown
- possibly due to trauma, especially extended hallux taking excessive pressure from footwear
45
Q
What is the pathology of Subungal Exostosis?
A
- Irritation and elevation of the periosteum from the surface of the bone
- Outgrowth of bone ossifies (bone creation)
- Appears as a ‘mushroom like’ formation consisting of bone cells
46
Q
What is the treatment of Subungal Exostosis?
A
- Conservative padding
- Footwear appraisal
- Referral for podiatric surgery - surgical procedure is called Exostectomy
47
Q
What is Onychomadesis?
A
- Seperation of the nail plate from the nail matrix from the proximal end to the distal
48
Q
What is the aetiology of Onychomadesis?
A
- Temporary cessation of nail growth
- Nail matrix inflammation
- If single digit - common causes are trauma, infection, subungal blistering
- If multiple digits - systemic illness, use of drugs
49
Q
What are Beaus Lines?
A
- Transverse ridges or grooves
- Caused by temporary cessation of nail growth
50
Q
What is Pterigium?
A
- Adhesion of Eponychium to nail bed following the destruction of the matrix
- Entire nail plate is eventually shed
- Associated with diminished peripheral circulation
51
Q
What is Pterigium Inversum?
A
- Attachment of the hyponychium to the distal end of the nail plate
52
Q
What is the aetiology of Pterigium Inversum?
A
- Systemic:
- Sclerosis
- SLE
- Raynauds
- poor peripheral circulation
- Local
- Lichen planus
- Trauma
53
Q
What is the treatment of Pterigium Inversum?
A
- Caution when cutting nails, as tissue could easily be cut when cutting nails
54
Q
What is Onychoschizia?
A
- Split in the nail plate
55
Q
What is Onychorrhexis?
A
- Also known as ‘reed nail’
- Brittle nails, longitudinal ridging
- May result in Onychoschizia
56
Q
What is Koilonychia?
A
- Spoon shaped nail
- Generally a result of deficieny anaemia such as iron
57
Q
What is Onychocryptosis?
A
Ingrown toe nail
58
Q
What are the clinical characteristics of OC?
A
- Nail spike in sulci, pus my exudate from the point of penetration in the sulcus
- Usually occurs in hallux
- Painful, acute tenderness
- Paronychia / presence of infection
- Swollen nail folds overlap nail plate
- Hypergranulation of tissue in chronic cases
59
Q
What is the aetiology of OC?
A
- Narrow tight-fitting footwear/hosiery
- Onychomycosis
- Involuted nails
- Hyperhidrosis
- Trauma
- Family history of OC
60
Q
what is the pathology of OC?
A
- Nail cut too short / injury occurs
- Protection is removed
- Nail grows forward, along the sulci, and spike presses into skin
