wk 6- different nail types and surgeries

Question 1

anatomy of nail

Answer 1

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)

Question 2

how far does the matrix extend

Answer 2

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

Question 3

how much does the nail bed contribute to the nail plate

Answer 3

10%

Question 4

what are causes of ingrown nails

Answer 4

-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)

Question 5

what is the academic word for ingrown nail

Answer 5

onychocryptosis (OC)

Question 6

classification of OC

Answer 6

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

Question 7

conservative treatment of ingrowns

Answer 7

-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

Question 8

what investigations should be made if theres a subungal mass

Answer 8

x ray
AP, isloated lateral view

Question 9

if concerned about vascular supply what investigations should be taken

Answer 9

ABI/TPI
regular HBA1c if DM

Question 10

what is mg/kg for lignocaine

Answer 10

3mg/kg

Question 11

PNA means

Answer 11

partial nail avulsion

Question 12

P and A means

Answer 12

phenol and alcohol

Question 13

TNA means

Answer 13

total nail avulsion

Question 14

NER means

Answer 14

nail edge resection

Question 15

sites for surgery can be

Answer 15

fibular edge (lateral)
or
tibial edge (medial)

Question 16

using phenol pros/cons

Answer 16

reduces risk of recurrence but increased risk of infection

Question 17

different types of nail surgery

Answer 17

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

Question 18

what changes can you make to the surgery

Answer 18

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

Question 19

what is chemical nail surgery indicated in

Answer 19

nail plate only deformity

Question 20

what two things are contraindicated in chemical procedure

Answer 20

hyperungulabia
subungal exostosis

cannot be combined with bone or soft tissue procedures

Question 21

what surgery is recommended for regrowth

Answer 21

excisional

Question 22

chance of regrowth with phenol

Answer 22

6%

Question 23

when would you use a nail avulsion without chemical

Answer 23

OM
trauma nail

Question 24

whats the alternate chemical to phenol

Answer 24

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

0-5% regowth

Question 25

what is sodium hydroxide neutralised by

Answer 25

acetic acid (5%)

Question 26

what is 20% ferric chloride used for

Answer 26

decrease post op bleeding and drainage post phenol matrixectomy

Question 27

MOA of phenol

Answer 27

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

Question 28

how long should phenol be apploed to matrix for

Answer 28

atleast 1 min

Question 29

recurrence rate for partial nail avulsion with phenol

Answer 29

1.1-4.3%

Question 30

safety of pehol for podiatrist

Answer 30

phenol is absorbed from the lungs, wear PPE

Question 31

indications for excisional matrixectomy

Answer 31

onychocryptosis and hyperungualabia (fleshy toes)

regrowth/spicule formation

inclusion cyst

cosmesis

bone pathology

Question 32

is excisional matrixectomy faster healing than phenolisation

Answer 32

yes- primary healing

Question 33

are there multiple excisional matrixectomy procedures

Answer 33

yes

Question 34

zadek procedure

Answer 34

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

Question 35

what is a winograd and frost procedure

Answer 35

partial nail excision/removal, sutured skin toward nail

Question 36

post operative dressings (7)

Answer 36

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

Question 37

post operative advice

Answer 37

• 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

Question 38

footwear advice post op

Answer 38

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

Question 39

advice to pt to manage healing capacity

Answer 39

-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

Question 40

when to contact clinic

Answer 40

• 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

Question 41

complications post op

Answer 41

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

Question 42

what causes misaligned nail

Answer 42

failure to cut parallel to edge of nail

Question 43

what is complex regional pain syndrome

Answer 43

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

Question 44

what is pyogenic granulomas

Answer 44

benign proliferation of capillary bloodvessels

Question 45

how long for acute post op osteomyelitis to occur

Answer 45

within 1 month

Question 46

what causes a split nail

Answer 46

scarring within nail matrix - poor technique

Question 47

how to remove pyogenic granulomas

Answer 47

curettage under LA with suture
freezing
silver nitrate

Question 48

when does infection typically occur post op

Answer 48

2-3 days