wk 6- different nail types and surgeries Flashcards

1
Q

anatomy of nail

A

nail plate (the actual nail)
lunula (white semi circle)
nail fold/cuticle (skin on proximal edge)
nail matrix (proximal to nail plate under the skin)
nail bed (distal to nail matrix, under the nail plate)

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2
Q

how far does the matrix extend

A

proximal to the EHL insertion and distal to the plantar aspect of distal phalanx

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3
Q

how much does the nail bed contribute to the nail plate

A

10%

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4
Q

what are causes of ingrown nails

A

-cutting technique
-intrinsic foot abnormalities (involuted nails, hyperextension of hallux, HAV, pes planus)
-geriatric
-medications
-systemic conditions (obesity, DM, arthritis
-onychomycosis
-trauma
-hyperhydrosis
-footwear
-genetics (hereditary)

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5
Q

what is the academic word for ingrown nail

A

onychocryptosis (OC)

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6
Q

classification of OC

A

stage 1- redness, slight swelling, pain (nail fold doesnt exceed nail plate)

stage 2-
a: pain, swelling, redness, serum drainage and or infection (nail fold exceeds nail plate <3mm)
b: (nail fold exceeds plate >3mm)

stage 3- granulation tissue and chronic hypertrophy of nail fold covering nail plate

stage 4- serious deformity of nail, both nail folds, and distal fold, hypertrophic tissue covering all edges

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7
Q

conservative treatment of ingrowns

A

-nail packing with cotton wool to separate nail fold from nail plate
-toe taping to pull nail fold away from nail plate
-cut nails straight across
-avoid tight footwear
-nail bracing

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8
Q

what investigations should be made if theres a subungal mass

A

x ray
AP, isloated lateral view

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9
Q

if concerned about vascular supply what investigations should be taken

A

ABI/TPI
regular HBA1c if DM

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10
Q

what is mg/kg for lignocaine

A

3mg/kg

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11
Q

PNA means

A

partial nail avulsion

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12
Q

P and A means

A

phenol and alcohol

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13
Q

TNA means

A

total nail avulsion

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14
Q

NER means

A

nail edge resection

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15
Q

sites for surgery can be

A

fibular edge (lateral)
or
tibial edge (medial)

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16
Q

using phenol pros/cons

A

reduces risk of recurrence but increased risk of infection

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17
Q

different types of nail surgery

A
  1. nail wedge avulsion- no chemical
    -partial, total
  2. chemical matrixectomy
    -partial, total
  3. excisional matrixectomy
    -partial, total, subungal exostectomy
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18
Q

what changes can you make to the surgery

A
  1. tournicot use
  2. length of chemical use
  3. method of application
  4. neutralising agent use
  5. post op dressing
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19
Q

what is chemical nail surgery indicated in

A

nail plate only deformity

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20
Q

what two things are contraindicated in chemical procedure

A

hyperungulabia
subungal exostosis

cannot be combined with bone or soft tissue procedures

21
Q

what surgery is recommended for regrowth

A

excisional

22
Q

chance of regrowth with phenol

A

6%

23
Q

when would you use a nail avulsion without chemical

A

OM
trauma nail

24
Q

whats the alternate chemical to phenol

A

sodium hydroxide (10%)
works just as well
less side effects

0-5% regowth

25
Q

what is sodium hydroxide neutralised by

A

acetic acid (5%)

26
Q

what is 20% ferric chloride used for

A

decrease post op bleeding and drainage post phenol matrixectomy

27
Q

MOA of phenol

A

causes subepidermal fibrosis that may stop communication between onychofibroblasts and regenerated epidermis

28
Q

how long should phenol be apploed to matrix for

A

atleast 1 min

29
Q

recurrence rate for partial nail avulsion with phenol

A

1.1-4.3%

30
Q

safety of pehol for podiatrist

A

phenol is absorbed from the lungs, wear PPE

31
Q

indications for excisional matrixectomy

A

onychocryptosis and hyperungualabia (fleshy toes)

regrowth/spicule formation

inclusion cyst

cosmesis

bone pathology

32
Q

is excisional matrixectomy faster healing than phenolisation

A

yes- primary healing

33
Q

are there multiple excisional matrixectomy procedures

A

yes

34
Q

zadek procedure

A

total matrixectomy- suture skin flaps together on dorsum aspect of nail

35
Q

what is a winograd and frost procedure

A

partial nail excision/removal, sutured skin toward nail

36
Q

post operative dressings (7)

A

topical anesthetics
topical antiobiotics
hydrocolloids
collagen alginates
antiseptics
dry gauze
foot soaks

37
Q

post operative advice

A
  • rest
  • foot elevated
    -dressing kept dry
  • paracetamol as pain relief, maybe NsaidS
    -Dressing change at 48 hours
    -go unshod when possible
    -discharge is normal, might experience some sudden sharp stabbing pain
    -review 2-7 days post op
38
Q

footwear advice post op

A

moderate to loose fitting shoes
if dont have appropriate shoes, cover whole foot in large tubular guaze

39
Q

advice to pt to manage healing capacity

A

-do not smoke, nicotine patches okay
-manage blood sugar levels
-elevate foot, no standing for long periods
-no sport for 3 weeks / minimise work load
- keep wound dry

40
Q

when to contact clinic

A
  • increase in pain
  • blood stain over 2cm in diameter on dressing
    -dressing too tight
  • dressing gets wet
    -loss of sensation
    -discolouration of skin area
    -if in doubt
41
Q

complications post op

A
  1. split nails
  2. misaligned nails
  3. complex regional pain syndrome
  4. pyogenic granuloma
  5. infection
  6. unreported allergy
  7. recurrence/regrowth
  8. phenol flare
42
Q

what causes misaligned nail

A

failure to cut parallel to edge of nail

43
Q

what is complex regional pain syndrome

A

pain occurs spontaneously or from a sensory stimulus is disproportionately more painful than it should be

44
Q

what is pyogenic granulomas

A

benign proliferation of capillary bloodvessels

45
Q

how long for acute post op osteomyelitis to occur

A

within 1 month

46
Q

what causes a split nail

A

scarring within nail matrix - poor technique

47
Q

how to remove pyogenic granulomas

A

curettage under LA with suture
freezing
silver nitrate

48
Q

when does infection typically occur post op

A

2-3 days

49
Q
A