Week 9 - Sublingual Hematoma, Nail Disorders & Ganglion

Question 1

What is a subungual hematoma?

Answer 1

Accumulation of blood under the nail matrix due usually to trauma
Incidence - Any age
History:
-Patients typically report finger was struck by a ham­mer  marked swelling/pain.
-Tight fitting boots, especially ski boots, are also common causes.
DDx - In the absence of physical trauma, suspect a Proteus or Pseudomonas infection

Question 2

What is the PE for subungual hematoma?

Answer 2

Exam:

1. May be only an area of dark, bluish discoloration under the nail
2. In more severe cases:
   - will be marked swelling with distention of the eponychium
   - quantity of blood may be sufficient to cause separation and ultimate damage and loss of the nail plate

Question 3

What is the etiology & symptoms of subungual hematoma?

Answer 3

Although relatively minor, this injury causes excruciating pain.
There is marked tension in the unyielding space bounded by the firm nail above and the bone below.
Relief of pain is immediate when the lesion is drained.

Question 4

What is the treatment for subungual hematoma?

Answer 4

• Best to permit early escape of the blood when it still is fluid.
• When the hematoma lies entirely under the nail, it may be necessary to make a small opening through the nail to permit its escape.
• This procedure is somewhat painful if much pressure is placed on the nail in the process!
• One option is to make an incision with the scalpel, cutting across the nail without much pressure.
• This allows drainage with minimal pain!
• Then make two oblique (“V”) incisions to make a larger hole .
• This permits continued drainage of blood and serum, prevents the hole from clotting shut and reforming the painful pressure!
• Be sure to use protective eyewear when draining a nail!

Burning a hole in the nail:
heat the tip of a straightened paper clip to red hot and carefully burn through the nail
a cautery pencil works as well.
For either technique, apply the hot metal to the nail for no more than 1 second at a time, or the heat will cause significant pain.
Be careful to not “burn” the underlying nail bed  worse pain!
You may have to repeat this several times to provide a hole that is large enough to remain open for continued drainage.

Just keep targeting the same hole made by the first pass.

All of these drainage techniques require the hematoma to be in a liquid state.

All methods are done without anesthetics.

When the hematoma extends toward the fingertip, the careful insertion of the tip of a pointed scalpel (or a large needle) just under the nail will permit drainage of the hematoma usually with little or no pain without needing to use anesthesia.

Question 5

Course & Complications of subungual hematoma:

Answer 5

Healing with any of these drainage methods is usually rapid without problems.
If the hole clots shut this soak the digit in cold water; adding peroxide will help dissolve the clot.
Sometimes blood stains remain until the nail plate grows out.
CAUTION – fracture may be hidden under a nail with significant damage – do X-ray!

Question 6

What is Onycholysis?

Answer 6

Definition – Detachment of nail from its bed at distal and/or lateral attachments.

Subungual space collects dirt and keratinous debris.

Typically grayish-white color due to presence of air under nail
But color varies from yellow to brown

Area may be malodorous.

Question 7

What are the etiologies of onycholysis?

Answer 7

Idiopathic

Systemic (e.g., thyrotoxicosis)

Congenital/hereditary

Cutaneous diseases (e.g., psoriasis, drug-induced photo-onycholysis)

Local causes (e.g., trauma, onychomycosis, chemicals).

Treatment – treat underlying condition(s)-

Question 8

What is Onychogryphosis?

Answer 8

Definition – thickening and distortion of the toenails or fingernails common in older people due to damage to the cells that grow the nail.

Question 9

What are some causes of Onychogryphosis?

Answer 9

Acute injury – dropping something on toe
Chronic injury – from ill-fitting shoes
Infection
Poor blood supply
Diabetes
Inadequate intake of nutrients.

Question 10

What are the symptoms of Onychogryphosis?

Answer 10

Discomfort from footwear/bed sheets pressing on thickened nails

Long deformed nails can impair walking.

Long curved nails can penetrate adjacent toes, causing pain and infection of the skin.

Question 11

What are the treatment options for Onychogryphosis?

Answer 11

Apply urea ointment (Ureacin-40) to soften nail.

Cut away excess hypertrophied nail with bone-cutting forceps.

Have the patient regularly file away the excess nail overgrowth.

Apply a moisturizer on nails each time you wash your hands or feet.

Soak the feet in warm salt water.

Remove entire nail and kill it with phenol.

Question 12

What are some ways to prevent Onychogryphosis?

Answer 12

Avoid footwear or stockings that gather at the toes.

Keep nails trimmed.

Avoid tight fitting foot wear.

Avoid nail polish.

Question 13

What is ONYCHOMYCOSIS?

Answer 13

Definition – chronic
progressive fungal infection
of the nail apparatus

Known as TINEA UNGUIUM

Question 14

What are some causes of onychomycosis?

Answer 14

May be Candida sp. (chronic paronyhcia) or molds.

Most fingernail and toenail infections caused by either trichophyton mentagrophytes or rubrum

T. rubrum was imported into industrialized nations from Europe during the 1800s and started an epidemic of foot and toenail infections!

Question 15

What are some symptoms of onychomycosis?

Answer 15

Symptoms:
In addition to unsightly appearance, onychomycosis of toenails can:
cause pain
predispose to secondary bacterial infections and ulcerations of underling nail bed

These complications are more common in immunocompromised individuals and diabetics.

Question 16

How do you diagnose onychomycosis in the lab?

Answer 16

Laboratory diagnosis:

KOH prep – confirm the species of fungus before starting oral antifungal treatment in tough infections.

Cultures:
Use a curette to obtain crumbling debris from both the proximal and distal areas of infection under several nails.

Or scrape the nail surface with a curette or a #15 scalpel blade.

Question 17

DDX of Onychomycosis?

Answer 17

Differential diagnosis:

Most commonly confused with psoriasis

The two diseases may coexist.

The single distinguishing feature of psoriasis, pitting of the nail-plate surface, is not a feature of fungal infection.

Leukonychia:

white spots or bands that appear proximally and proceed out with the nail
caused by minor trauma
may be confused with proximal subungual onychomycosis.

Eczema or habitual picking of the proximal nail fold induces the nail plate to be wavy and ridged, but its substance remains intact and hard.

Question 18

What are the treatment options for Onychomycosis?

Answer 18

Various treatments of theses several conditions are covered in the Dermatology course and will not be addressed here.

Removal of the nail may be needed at times along with medical treatment to help clear a fungal infection of the nail.

Question 19

What is a Ganglion Cyst?

Answer 19

Definition – cystic swellings surrounded by a fibrous tissue wall occurring in the vicinity of joint capsules and tendon sheaths

Question 20

What are the causes of Ganglion Cyst?

Answer 20

Cause:
Not fully understood
May be a degenerative process in the mesoblastic tissues surrounding the joint
May also be a herniation of a tendon sheath.
The relation of trauma has not been definitely determined.

Question 21

What is the incidence of Ganglion Cyst?

Answer 21

Incidence:
Occur three times more commonly in females than in males.

Majority appear in the second and third decade

Question 22

Location of Ganglion Cysts?

Answer 22

Location is variable:
Most common site is the dorsum of the wrist
Followed by the flexor aspect of the wrist adjacent to the radial artery.
Potentially found in all joint capsule or tendon areas including the elbow, ankle, foot and back of the knee (Baker’s Cyst).

Question 23

PE findings of Ganglion Cyst?

Answer 23

Typically a prominent mass
Easily visible sub-Q around the joint
Flexion or extension of the joint makes the mass more visible.
Consistency is variable:
Usually smooth and rounded; at other times multilocular
Usually hard/firm – often misdiagnosed as a bony or cartilaginous lesion
May be cystic and definitely fluctuant.

Size is variable – often increases in size after excessive movement or use of the part and decreases with rest.

Content – upon aspiration, most have a crystal clear, very thick gelatinous content occasionally tinged with blood.

Pain:
Frequent symptom when ganglion first appears.

Or it may be painless!

Pain may be dull and constant
Or it may appear or reoccur following the use of the affected part.

Pressure upon the ganglion may  definite sharp pain particularly if located on the flexor tendon sheaths in the palm, where grasping a hard object causes extreme pain.

May be an associated weakness of the area involved by the ganglion, such as the wrist, the finger, or the toe.

Question 24

Treatment for Ganglion Cyst?

Answer 24

Indications – patient wants:
Relief of the pain/soreness
Removal of the unsightly mass
Relief of the feeling of weakness of the part

Four historical treatment methods: 
Rupture
Aspiration
Injection of sclerosing solutions
Excision

Question 25

How do you Rupture a Ganglion Cyst?

Answer 25

Historic practice was rupture of the ganglion by striking it with a heavy book or applying sharp finger pressure

Dramatic, but permanent cure rate is quite low.

This technique is no longer recommended and is considered malpractice!

Question 26

How do you Aspirate a Ganglion Cyst?

Answer 26

Use large bore 14-16 gauge 1” needle attached to a syringe.
Often contents of the ganglion are so firm and jellylike that aspiration may be unsuccessful.
May be difficult to be certain that the contents of a multilocular ganglion cyst are entirely evacuated from all lobes!
OVERALL – aspiration of the ganglion contents has been disappointing.

Question 27

How do you Aspiration & Injection of Sclerosing Agent for Ganglion Cyst?

Answer 27

Aspirate all the material, remove the syringe and leave the needle in place for injection of a sclerosing solution.
One choice is sodium morrhuate; usually 1 or2 injections (at most) are required.
The injections produce moderate pain and local edema that lasts a day or two, but is not disabling.
Mixed results are obtained!

Question 28

Excision for Ganglion Cyst?

Answer 28

Most successful treatment is careful dissection and excision by a specialist!
Technique:
Use local infiltration anesthesia.
Separate the ganglion from surrounding tissue by blunt and sharp dissection.
Excise a generous amount of the surrounding tissue at the base of the ganglion to try to insure against recurrence.
There is no guarantee of cure!

Question 29

Course & Complications of Ganglion Cysts Treatments

Answer 29

Aspiration – infection is a risk
Sclerosing agent may damage surrounding structures!
Cure rate is only 50-80% for any of the above four methods.
If the ganglion is left alone, a high percentage will rupture spontaneously during the next three years.