Toenail Surgery

ajkim1's version from 2015-05-07 23:44


Question Answer
Global period for a toenail10 days
Nail plate is equivalent to _______ of skinStratum corneum
Nail bed is derived from _______Stratum germinativum
Lunula represents junction between _______ and _______Matrix and bed
What part are we actually removing in a partial or permanent procedure?Germinal matrix
HyponychiumEpidermis at free end of nail plate
Eponychium?Thin cuticular fold at proximal nail fold
Cuticle?Adheres to proximal nail plate, protects matrix
What forms the specialized keratin nail plate?Matrix
What's the most common organism of paronychium?Staph
What are the 2 secondary organisms of paronychia?Pseudomonas, Candida
What is the 3rd common benign tumor of the nail unit, and what is it?Pyogenic granuloma is hypertrophic vascular tissue secondary to trauma or infection
What is the 2nd common benign tumor of the nail and how does it present?Myxoid cyst is smooth, fleshy to pink colored nodule, translucent, compressible
What are the consequences of the impinging nail matrix of a mixed cyst?Longitudinal groove and nail plate thinning
What's a periungual verrucae?Benign fibre-epithelial growth with rough HPK surface- HPV
What's a periungual fibroma?Rare lesion of the proximal nail fold, may be a marker of tuberous sclerosis
What's a subungual exostosis?Painful outgrowth of normal cartilage bone
What's a glomus tumor?Small, intense, pulsating, spontaneous, painful lesion beneath nail, small bluish to reddish blue, several mm in diameter
What's the most common malignant tumor of the nail?Squamous cell carcinoma
What would indicate malignant melanoma and how does it look?Hutchinson's sign is a line a hyper pigmentation in nail
What are the different types of onychocryptosis?Neonatal, infantile, adolescent, adult
What is neonatal ocychocryptosis and do we treat it?Free nail margin has not yet overgrown tip of the toe, treat it by massaging
What is infantile onychocryptosis and how do we treat it?Congenital malalignment of the big toenail (operation if not healed by 2 years) and hypertrophic lateral lip (massage)
What is adolescent onychocryptosis and how do we treat it?Distal lateral ingrown due to narrow nail bed, treat by packing, taping, gutter, selective lateral matrix horn resection
What is adult onychocryptosis and how do we treat it?Sharply bent lateral margin, treat by packing, gutter, surgical narrowing of nail
Distal embedding and treatmentHallux nail is too short, treat by taping the hyponychium, surgery
Retronychia and treatmentChronic trauma with marked onycholysis leading to proximal ingrown, treat with proximal nail avulsion
Pincer nail and treatmentWide base of the distal phalanx with large medial and smaller lateral osteophytes, treat with orthonyxia (braces), or narrowing of nail (nail bed pasty in severe cases)
Classification system for ingrown hallux nailsMozena
What is the treatment goal of ingrown nails?Ungual labia fold of less than 3mm
Stage I Mozena and treatmentErythema, slight edema, pain when pressure applied to lateral fold, treat conservatively
Stage IIa Mozena and treatmentIncreased stage I symptoms, drainage, and infection, nail fold less than 3mm, treat conservatively with matrixectomy with hypertrophic ungulate labia fold reduction
Stage IIb Mozena and treatmentIncreased stage I symptoms, drainage and infection with nail fold 3mm or greater, treat conservatively with matrixectomy with hypertrophic ungulate labia fold reduction
Stage III Mozena and treatmentMagnified stage II symptoms, granulation tissue, and nail fold hypertrophy, treat with matrixectomy with hypertrophic ungual labia fold
What are some forms of conservative treatment for an ingrown toenail?Slant back of nail border, cut nails straight across, place cotton under bad edge, tension wiring of borders, relieve granuloma with serial silver nitrate application, remove offending nail, no Ab needed
When do we utilize Ab for ingrown toenail?If we suspect paronychia
How do we do a skin plasty (Duvries)?Remove longitudinal ellipse of skin from side of the toe and suture the defect together, moving hypertrophied labia planetary from contact with the nail plate
When are matrixectomies indicated?Symptomatic nail dystrophy, recalcitrant recurrent onychocryptosis
What procedures leave the nail matrix undisturbed to allow re-growth of the nail plate border?Partial and total nail avulsion
Ablation matrixectomyMechanical destruction of germinal matrix, chemically with NaOH, phenol, laser
Excision matrixectomy"Cold steel" removal of offending nail plate border, germinal matrix, and hypertrophied labia
What structure must be avoided with an excision matrixectomy?Insertion of extensor tendon on distal phalanx
Phenol neutralizerBlood
NaOH neutralizerVinegar or 5% acetic acid
Examples of excision matrixectomyWinograd, suppan, kaplan, terminal syme
WinogradGood for hypertrophic nail folds, make a longitudinal incision through nail bed, 2nd incision through skin at nail fold, wedge of tissue removed down to periosteum, curette, close
FrostInverted L incision through long axis of nail to periosteum, skin flap freed from matrix, nail matrix removed, close
ZadikTotal nail avulsion, 2 lateral incision, 1 horizontal, matrix excised, close
SuppanTotal nail avulsion, #15 blade parallel under eponychium, blade drawn medial to lateral over entire matrix, angled planetary against bone, matrix resected, acisional (will probably grow back)
KaplanTotal nail avulsion, 2 proximal incision, 1 distal incision, entire nail bed/matrix is removed from distal phalanx, for subungual exostosis
Terminal SymeTotal nail excision, removal of distal 1/3 terminal phalanx, for subungual osteoma, glomus tumor, mallet toe, macrodactyly, OM
How do we treat burn wounds?Silvadene daily with warm H20 soaks, epsom salts, pedi-boor, debridement
Rosenthal zone I and treatmentNail bed tissue loss distal to bony phalanx, treat by cleaning wound, deriding, allowing to granulate, skin graft if >1cm
Rosenthal zone II and treatmentDistal to lunula, exposure of distal phalanx, decried including bone, possible flap closure
Rosenthal zone III and treatmentProximal to distal end of lunula, minimal nail bed survival, OR debridement, excise nail plate, terminal Syme's amputation
20% associated with distal phalanx fractureSubungual hematoma
What if >25% of nail plate is taken over by subungual hematoma?Nail plate avulsion
Laceration treatmentIrrigate, absorbable suture, dressing
What biomechanics deformity will result if fractured tibial sesamoid isn't taken out properly?Hallux varus
Etiology of sesamoid fracturesDirect force, sudden forced hallux dorsiflexion (1st MTPJ dislocation), stress fractures
Non-displaced digital fracture treatmentImmobilization
Displaced digital fracture treatmentClose-reduced, ORIF (if closed-reduced fails)
Most common lesser digital fractureSpiral-oblique, 5th toe
Hallux fracture treatmentGutter splint, NWB