Nail Surgery Tips - moderm.org€¦ · Nail Surgery Tips Molly Hinshaw, MD Associate Professor, ... Dumontier C. Basic and Advanced Nail Surgery. In: Nails Dx, Rx, ... Nail Biopsy

Nail Surgery Tips

Molly Hinshaw, MDAssociate Professor, UWSMPH

Dermatology & [email protected]

No Conflicts of Interest to Declare

“The content of this presentation does not relate to any product of a commercial interest; therefore, there are no relevant financial relationships to disclose.”

Indications for Nail Surgery

• Melanonychia-with unusual features• Onychodystrophy-single nail• Onychodystrophy-multiple nails, rapidly evolv• Subungual pain• Erythronychia-single nail

Surgical Approaches

• Tangential shave biopsy/excision• Lateral longitudinal excision• Excision: matrix, bed• Punch biopsy: matrix, bed• (Mohs)

Pre-Intra-Post-Op Issues for All Nail Surgeries

• Pre-Op: Pt education• Intra-Op: Surgical Tray; Asepsis• Intra-Op: Anesthesia• Intra-Op: Suture choice• Post-Op: Pain Management

Insert postop care handout here

Intra-Operative: Antisepsis

Surgery: Minimizing Infection Risk

• Apply glove to patient’s hand• Control bleeding with pressure, tumescence• Daily dressing changes • Limit activity, trauma

Antisepsis• Pre-operative scrub with alcohol alone or with + chlorhex

or iodophore alone OR chlorhexidine OR iodophor

Rutala WA, Weber DJ. Disinfection, sterilization, & antisepsis: An overview. Amer J Infect Control 2016;44:1-6e

Intraoperative: Anesthesia

Comparison Proximal Block During Laceration Repair:

Single sq Volar vs Two Lateral• Randomized, prospective, 50 pts>18y/o (78% male) in ED with finger

laceration any digit, n=63, 1 investigator, used lido 2% w/epi 0.0125mg/mL• Single sq volar: 3mL inject vertically through distal joint line of volar MCP• Dual Dorsal: 1.5mL on each side, enter dorsally, inject half, push needle

thru & inject rest volar• Outcomes: 1. pain during anesthesia, 2. pain during suturing 3. onset time

of total anesthesia, 4. need for additional aesthesia • Visual analog scale (VAS) 0-100 used for pain score• Conclusions: No statistical difference in any of 4 measures. “Single

injection volar nerve block technique is suitable for digital anesthesia in emergency departments”

Okur, OM. Two injection digital block vs single subcutaneous palmar injection block for finger lacerations. Eur J Trauma Emerg Surg 2016; DOI 10.1007/s00068-016-0727-9

Comparison of Proximal Blocks: Single sq Volar vs Two Lateral

• Randomized, prospective 86 pts>18y/o in ED with finger injury (laceration (n=63), dislocation, crush, fracture, infection, other), multiple surgeons, lidocaine 1% without epi

• Also did not limit to digits 2, 3, 4• Single volar (n=41) performed via sq (not transthecal) route, 2-3mL• Double dorsal (n=27)=1mL each side of proximal phalanx just distal to

MCP• 1° outcome=Pain score during injection; 2°=pain of injury 5 min after

anesthesia, success of anesthesia defined as ability to proceed without additional anesthesia, complications

• Conclusion: No statistical difference in single volar and “double dorsal” proximal block injection pain or anesthesia effectiveness

Martin SP. Double-dorsal vs. single-volar digital subcutaneous anesthetic injection for finger injuries in the emergency department: A randomized controlled trial. Emerg Med Austral 2016;28:193-8.

Intraop: Useful Surgical Tray

Pre-Intra-Post-Op Issues for All Nail Surgeries

• Pre-Op: Pt education• Intra-Op: Asepsis• Intra-Op: Anesthesia• Intra-Op: Suture choice• Post-Op: Pain Management

Post-Surgical Pain Medication by Surgery

Surgery• Avulsion *• Phenolization *• Biopsy *• Shave excision **• Fusiform longit. excision **• Lat longitudinal excision***• Flaps ***• Nail Unit Graft ***

Pain Medication• *=APAP or NSAIDS• **=T3 or other mild opioid• ***=morphine and its derivatives

Abimelec P, Dumontier C. Basic and Advanced Nail Surgery. In: Nails Dx, Rx, and Surgery Scher RS & DanielsCR Eds. Elsevier 2007.





Melanonychia

Atypical• Single nail in a Caucasian• Unusual band nonCaucasian• A-peak 5th-7th decade, AA• B-br/black, >3mm, borders• C-change• D-digit affected• E-extension (Hutchinson’s)

No Need for Bx• Melanocyte activation-multiple nails,

greyish• Uniform bands African Am, Asian

Levit EK, Kagen MH, Scher RK, et al. The ABC rule for clinical detection of subungual melanoma. J Am Acad Dermatol 2000;42:269-74.

Nail Unit Melanoma

• 2/3 present as melanonychia (distal matrix)• Thumb>Grt Toe>Index finger dominant hand• Typically >5mm broad• 5 year survival invasive MM=15-85% (30%)

Jefferson J, Rich P. Melanonychia. Dermatol Res and Practice 2012;1-8.

Case: Melanonychia

Nail Templates Help Keep the Specimen Flat for Processing & Interpretation

Inspect Nail Plate and Consider Submitting the Portion over the Lesion

Melanonychia: Tangential Shave

• Described by Haneke in 1999• Low risk nail dystrophy • Useful for thin matrix lesions of any size but esp if over 3mm• If exam reaveals popular lesion, then incisional/punch bx

Indications for Nail Biopsy


Single Nail Dystrophy

What Is Your Preferred Surgical Approach?

A. ExcisionB. Tangential shave of matrixC. Punch biopsy of bedD. Nail matrix/bed excisionE. None of the above

Onychomatricoma

• Benign, slow growing fibroepithelial tumor• Adults, typically caucasians, M=F• Longitudinal thickening, xanthonych, honeycomb, proximal

splinter hemorrhages• Also may present as longitud. melanonychia• Nail clipping may be useful for diagnosis3

• Ddx=SCC, onychomycosis, onychopapilloma• Treatment: Surgical



This Patient Is Most Likely a:

A. ChildB. Teenage femaleC. Teenage maleD. 30-50 y/o femaleE. 30-50 y/o maleF. None of the above

D: 30-50y/o Female

• Most (up to 90% in some series) glomus tumors affect this demographic

Van Geertruden J, et al. Glomus tumours of the hand. J Hand Surg 1997;21B(2):257-60.

What Is Your Preferred Surgical Approach?

A. Lateral Longitudinal ExcisionB. Tangential shave of matrixC. Punch biopsy of bedD. Nail matrix/bed excisionE. None of the above

Glomus Tumor



Case

• 64 M • Cc=periodic sticky substance exudes from area• Present 9 years• Painless

Summary: Erythronychia

• Single nail dystrophy esp. chronic, refractory warrants inspectionJellinek N. Longitundinal erythronychia: Suggestions for evaluation and management. J AmerAcad Dermatol. 2011;64(1):167.e1-11.

Recap: Nail Bx Indications and Techniques

• Melanonychia: matrix tangential shave• Onychodystrophy: example of matrix/bed excision• Subungual pain: example of incision• Erythronychia-example of tangential shave

Summary

• Pt preparation for surgery is critical• Must visualize probable origin of pathology• Choice of bx technique=tailored to origin of process and type

of process being sampled• Use partial avulsions, submit plate if has dx value, replace plate

Thank you!Molly Hinshaw, MD

[email protected]

Nail Surgery Tips - moderm.org€¦ · Nail Surgery Tips Molly Hinshaw, MD Associate Professor, ... Dumontier C. Basic and Advanced Nail Surgery. In: Nails Dx, Rx, ... Nail Biopsy

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