nail surgery tips - moderm.org€¦ · nail surgery tips molly hinshaw, md associate professor, ......
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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.
Indications for Nail Surgery
• Melanonychia-with unusual features• Onychodystrophy-single nail• Onychodystrophy-multiple nails, rapidly evolv• Subungual pain• Erythronychia-single nail
Indications for Nail Surgery
• Melanonychia-with unusual features• Onychodystrophy-single nail• Onychodystrophy-multiple nails, rapidly evolv• Subungual pain• Erythronychia-single nail
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
• Melanonychia-with unusual features• Onychodystrophy-single nail• Onychodystrophy-multiple nails, rapidly evolv• Subungual pain• Erythronychia-single nail
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
Indications for Nail Biopsy
• Melanonychia-with unusual features• Onychodystrophy-single nail• Onychodystrophy-multiple nails, rapidly evolv• Subungual pain• Erythronychia-single nail
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
Indications for Nail Biopsy
• Melanonychia-with unusual features• Onychodystrophy-single nail• Onychodystrophy-multiple nails, rapidly evolv• Subungual pain• Erythronychia-single nail
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
