Nail Surgery

Question 1

The fingers and toes have paired sensory volar and dorsal digital nerves.

Answer 1

T

Question 2

The dorsal nerves reach the distal phalanx of only the 2nd-4th digits.

Answer 2

F 1st and 5th only.

Question 3

The distal nail bed attaches to the dorsal aspect of the processus unguicularis, a horshoe shaped rough bone excrescence at the tip of the distal phalanx.

Answer 3

T

Question 4

The interosseous ligaments attach to the lateral spines of the processus unguicularis.

Answer 4

T

Question 5

The germinative part of the nail unit is the cuticle and eponychium.

Answer 5

F Matrix and nail bed.

Question 6

the distal or ventral matrix is the most proximal portion of the nail bed epithelium.

Answer 6

T

Question 7

The nail bed extends from the matrix to the onychodermal band.

Answer 7

T

Question 8

The nail plate is the product of the nail bed.

Answer 8

F Product of nail matrix.

Question 9

Blood glucose levels are unimportant in diabetic patients undergoing toenail surgery.

Answer 9

F Need to be well controlled prior to toe surgery.

Question 10

2-3mL of plain 2% lignocaine or prilocaine can be used per digit when performing a proximal digital block.

Answer 10

T

Question 11

Splinting of the finger may be indicated after complex nail surgery

Answer 11

T

Question 12

After nail surgery, it is not necessary to elevate the extremity.

Answer 12

F Should elevate for two days.

Question 13

A transthecal block is performed from the dorsal crease of the MCP joint.

Answer 13

F Volar crease.

Question 14

In a distal wing block, the injection points are distal to the DIP joint creases.

Answer 14

T

Question 15

There is a general rule that the more superficial a nail change is, the more proximal the pathogenic process must be.

Answer 15

T

Question 16

Nail clippings do not need to contain subungual hyperkeratosis.

Answer 16

F Should contain as much as possible.

Question 17

Clippings performed for H&E give almost double the rate of positives compared to mycological culture.

Answer 17

T

Question 18

A lateral longitudinal nail biopsy is appropriate for all diagnostic purposes, provided the nail pathology is in the lateral portion of the nail apparatus.

Answer 18

T

Question 19

In a lateral longitudinal nail biopsy, a straight longitudinal incision starting at the distal crease of the DIP joint is carried to the tip about 2mm centrally from the lateral nail plate margin, and a second incision parallel to the first one along the lateral nail margin in the depth of the nail groove.

Answer 19

T

Question 20

The lateral fold should be included in a longitudinal nail biopsy.

Answer 20

F

Question 21

Matrix biopsies are the most important for most nail diseases.

Answer 21

T

Question 22

A superficial matrix biopsy is unhelpful for diagnosing longitudinal melanonychia.

Answer 22

F

Question 23

There will be no post-operative nail dystrophy after a superficial matrix biopsy, provided the biopsy is less than 1mm thick.

Answer 23

T

Question 24

Biopsies of the proximal nail fold can be performed as a 2mm punch or as a narrow wedge with its base being at the free margin of the nail fold.

Answer 24

T

Question 25

Distal nail avulsion is the classical method of nail avulsion.

Answer 25

T

Question 26

During maneuvers in distal nail avulsion, the blunt tip of the elevator points away from the nail plate.

Answer 26

F Always points to the nail plate.

Question 27

Distal nail avulsion is less traumatic than proximal nail avulsion.

Answer 27

F

Question 28

Proximal nail avulsion is particularly useful when there is thick sunbungual hyperkeratosis.

Answer 28

T

Question 29

Repeated nail avulsion causes thickening and overcurvature of the nail plate or nail dystrophy.

Answer 29

T

Question 30

Matricectomy is the complete removal of the germinal matrix.

Answer 30

T

Question 31

Nail ablation is definitive extirpation of the entire nail organ.

Answer 31

T

Question 32

Matricectomy can be performed with surgery or adjunctive phenolisation, electroradiosurgery or carbon dioxide laser.

Answer 32

T

Question 33

With total nail ablation, the incision is made just inferior to the hyponychium.

Answer 33

F Down to bone.

Question 34

Large nail haematomas do not require any further investigation prior to treatment.

Answer 34

F x-rays are mandatory.

Question 35

After trauma the nail plate is removed for appropriate examination of the mail bed and matrix, cleansed and stored under sterile conditions

Answer 35

T

Question 36

Wet gauze only should be used to clean blood from the nail bed and matrix after nail trauma

Answer 36

F Sometimes 3% hydrogen peroxide is needed for cleaning

Question 37

Approximately 20% of severe nail bed injuries have an accompanying fracture.

Answer 37

F 50%

Question 38

Common sequelae of trauma of trauma on onycholysis, split mail, ptertgium, various nail dystrophies, hook nail and malalignment

Answer 38

T

Question 39

Foreign bodies under the nail plate are generally not painful

Answer 39

F Intense pain.

Question 40

Tetanus prophylaxis should be considered if wooden splinters are lodged under the nail plate.

Answer 40

T

Question 41

Periodical clipping of the gryphotic nail is often adequate to keep it under control.

Answer 41

T Can perform warm foot bath to soften nail, or use 40% urea, 50% KI ointment.

Question 42

Gryphotic nails tend to be firmly attached to the nail bed.

Answer 42

F Loosely attached.

Question 43

Phenolisation is ineffective for avulsing a gryphotic nail.

Answer 43

F Safest and easiest method.

Question 44

Nail avulsion with phenol involves vigorously rubbing liquefied phenol into the matrix and sulci for 2-3 minutes once the nail plate is removed.

Answer 44

T

Question 45

Pain after nail avulsion with phenol is typically severe.

Answer 45

F minimal

Question 46

Healing after nail avulsion with phenol takes 2-3 weeks.

Answer 46

T Should do daily foot baths while healing.

Question 47

50% sodium hydroxide can be used as an alternative to phenol for nail avulsion of the gryphotic nail.

Answer 47

F 10% sodium hydroxide.

Question 48

Nail spicules can occur if the lateral matrix horns are incompletely removed following surgical matricectomy.

Answer 48

T

Question 49

The most successful treatment for pachyonychia congenita is vigorous curettage plus electrodessication of the matrix.

Answer 49

T

Question 50

In pachyonychia congenita keratins 6a/16 and 6b/17 are present in the nail bed but not in the matrix

Answer 50

T 6a/16 – PC of Jadassohn-Lewandowsky 6b/17 – PC of Jackson-Lawler Therefore a nail plate has normal structure but overlies a huge nail bed hyperkeratosis

Question 51

In pachyonychia congenital the nail plate production has to be eliminated because the nail plate formed in a correct manner by the matrix cannon adhere to the pathological nail bed

Answer 51

T

Question 52

Lateral longitudinal nail biopsies are used to narrow racket nails.

Answer 52

T

Question 53

Ingrown toenails are most commonly seen in neonates, infants and the elderly. .

Answer 53

F Adolescents and young adults

Question 54

Neonatal ingrown toenails should be treated aggressively.

Answer 54

F Conservatively. Daily massage with lubricant.

Question 55

Neonatal ingrown toenails are due to a distal nail wall resulting from too short a nail plate.

Answer 55

T

Question 56

Congenital hypertrophic lip of the hallux is characterised by a grossly hypertrophic medial nail fold

Answer 56

T

Question 57

Congenital hypertrophic lip of the hallux tends to disappear spontaneously after several months.

Answer 57

T

Question 58

Congenital malalignment of the great toenail refers to medial deviation of the long axis of the great toenail.

Answer 58

F Lateral deviation.

Question 59

Ingrown toenails in adolescents occur due to a wide curved nail and a narrow nail bed.

Answer 59

T

Question 60

In congenital malalignment of the great toenail, the malpositioned nail has no attachment with the nail bed.

Answer 60

T

Question 61

In congenital malalignment of the great toenail if the nail reattaches it will take on a normal appearance and its axis will be normal

Answer 61

F Axis will remain oblique

Question 62

Aside from its deviation, nails with congenital malalignment of the great toe nail otherwise appear normal.

Answer 62

F Grayish-green discolouration, oyster-shell like appearance.

Question 63

Oncyholysis is most important for the prognosis of congenital malalignment of the great toenail. .

Answer 63

T

Question 64

Surgery is deemed necessary if there is no substantial improvement in congenital malalignment of the great toenail by the age of 2 years.

Answer 64

T

Question 65

Repair of congenital malalignment of the great toenail involves performed a cresenteric rotation flap

Answer 65

T

Question 66

Untreated nail malalignment inevitably will spontaneously resolve.

Answer 66

F Develops into early onychogryphosis.

Question 67

The mechanisms responsible for formation of a juvenile ingrown nail all lead to a relative compression of the tip of the toe, so that the distal end of the nail has no more room and grows into the lateral nail folds.

Answer 67

T

Question 68

There are three clinical stages of a juvenile ingrown toenail: 1. Erythema, oedema, pain on pressure 2. Infection and drainage 3. Granulation tissue and lateral nail wall hypertrophy.

Answer 68

T

Question 69

For the adolescent-type ingrown nail, surgical avulsion of the nail alone has a cure rate of 70%.

Answer 69

F Recurrence rate of 70%.

Question 70

Phenol cautery should not be used for treating adolescent-type ingrown nails due to its high recurrence rate.

Answer 70

F Has very low recurrence rate.

Question 71

A distal wall is commonly the consequence of avulsion of the big toenail or when it was cut very short for too long a time.

Answer 71

T

Question 72

Surgical treatment of a distal nail wall involves a fish mouth incision parallel to the distal groove around the tip of the toe.

Answer 72

T

Question 73

Treatment for retronychia is generally conservative.

Answer 73

F Nail avulsion by proximal approach.

Question 74

Pincer nails are characterised by transverse overcurvature increasing distally along the longitudinal axis of the nail.

Answer 74

T

Question 75

The pain associated with a pincer nail is usually unbearable.

Answer 75

F Surprisingly mild.

Question 76

Pincer nails can either have symmetrical or asymmetrical involvement.

Answer 76

T

Question 77

Surgical treatment of a pincer nail is aimed at flattening it.

Answer 77

T

Question 78

If acute paronychia does not improve after 2 days of treatment with antibiotics, surgical treatment is necessary.

Answer 78

T The nail matrix of children can be destroyed within 48 hrs of acute bacterial infection.

Question 79

Acute paronychia involves removal of the distal one-third of the nail.

Answer 79

F Proximal.

Question 80

Chronic paronychia is usually painful | .

Answer 80

F

Question 81

Chronic paronychia manifests with retraction of the perionychial tissue, detachement of the nail from the overlying thickened nail fold, and loss of the cuticle.

Answer 81

T

Question 82

Viral warts are the most common reactive tumours of the nail apparatus

Answer 82

T

Question 83

Cryotherapy of nail warts should be performed at 6 weekly intervals.

Answer 83

F Weekly or biweekly.

Question 84

Excision of ungual fibrokeratomas should be carried out around its base down to the bone.

Answer 84

T

Question 85

Subungual exostoses are commonly seen on the distal medial aspect of the terminal phalanx of the great toe.

Answer 85

T But may occur at any other digit.

Question 86

Myxoid cysts generally occur in the absence of any bone pathology.

Answer 86

F Assoc with degenerative OA of the DIP joint.

Question 87

There are no methods of determining whether a myxoid cyst is attached to the distal interphalangeal joint.

Answer 87

F Intra-articular injection of methylene blue will show connection.

Question 88

Epidermoid carcinoma (IEC and SCC) is the most frequent malignant nail tumour.

Answer 88

F Second most frequent. Melanoma is most frequent.

Question 89

Epidermoid carcinoma of the nail can present as longitudinal melanonychia.

Answer 89

T

Question 90

Metastases are common from epidermoid carcinomas of the nail.

Answer 90

F Rare.

Question 91

Carcinoma cauniculatum is a variant of verrucous carcinoma that rarely occurs under the nail. It should be excised with Mohs due to the high risk of metastasis.

Answer 91

F Almost never metastasizes, but everything else is true.

Question 92

Unugual melanomas are always pigmented.

Answer 92

F 66-75% are pigmented.

Question 93

Amputation of the digit in cases of ungual melanomas is associated with better survival rates.

Answer 93

F Conservatively operated pts have longer disease-free survival times.

Question 94

The treatment of unugual melanomas should also include sentinel lymph node biopsy.

Answer 94

F No unanimous opinion on this.

Question 95

The classical repair of a split nail is excision of the scar and meticulous repair.

Answer 95

T

Question 96

Matrix grafting is the treatment of choice for wide nail splits and most cases of pterygium.

Answer 96

T

Question 97

In nail surgery, tourniquets can be left on up to a maximum of 30 minutes.

Answer 97

F 20 minutes.

Question 98

Pain after nail surgery is common and may sometimes be excruciating

Answer 98

T

Question 99

Pain after nail surgery typically develops after 24-48hrs.

Answer 99

F This is suspicious for an infection.

Question 100

Pain starting 10 days or longer after nail surgery is suspicious for reflex sympathetic dystrophy and requires intensive treatment to prevent it from becoming chronic.

Answer 100

T

Question 101

Necrosis can occur after nail surgery if the sutures are too tight and not removed in time.

Answer 101

T

Question 102

Stiffening of the distal interphalangeal joint after nail surgery is uncommon.

Answer 102

F Common – pts should hold finger in physiologic flexion.

Question 103

The classical split nail repair is excision of the scar and meticulous repair. A narrow strip of nail is avulsed over the split, leaving the lateral portions attaches to the matrix and nail bed

Answer 103

T Great toe nail may be a superior donor site

Question 104

In repair of matrix defects in the case of a pterygium the depth of the proximal groove is recreated

Answer 104

T