Removal Of Nail Plate Research Articles

Approach to nail trauma for primary care physicians.

To provide an overview and approach to common nail bed injuries seen by primary care practitioners. An Ovid MEDLINE literature search was performed using search terms and studies were graded based on level of evidence. Nail trauma is common in primary care practice and requires proper and prompt treatment to avoid lasting effects on finger function and cosmesis. When presented with a fingernail injury, primary care physicians should perform a thorough physical examination to determine extent of injury; take a history to rule out notable risk factors; perform a comprehensive neurovascular examination to assess pulp capillary refill, to do a 2-point discrimination, and to compare with an uninjured digit; and evaluate range of motion. Clinical evaluation may require local anesthesia and a tourniquet. Nail bed trauma can present in different ways and includes subungual hematomas, distal phalanx fractures, Seymour fractures, and-in more severe cases-fragmentation or avulsion of the nail bed. Treatment for subungual hematomas where the nail plate is intact does not require nail plate removal and nail bed exploration; however, exploration and repair are indicated for a nail plate injury, a proximal fracture involving the germinal matrix, and a distal phalanx fracture requiring stabilization. Fingertips are essential to normal hand function. Nail trauma is common and can be managed by primary care physicians. Shared decision making concerning management is based on the mechanism and extent of the injury and aims to prevent secondary deformities.

Rethinking the Need for Nail Plate Removal: A Comparison of the Risks Between Standard Nail Bed Repair and Nonoperative Management.

Nail bed injuries are commonly treated with nail plate removal and repair due to concern for future nail deformity. There is controversy whether this is necessary. We compared the outcomes for adult patients with simple nail bed lacerations who underwent either formal nail bed repair or nonoperative management. A retrospective cohort study was performed of adult patients with nail bed lacerations from 2012 to 2019. Nail bed lacerations were diagnosed in patients with fingertip injuries resulting in subungual hematoma greater than 50% or in any subungual hematoma in the setting of a distal phalanx fracture. All patients included had an intact nail plate. Patients were treated with nail bed laceration repair or nonoperatively without nail plate removal. The primary outcome was the development of a nail deformity. Secondary outcomes included infection, fracture nonunion, and patient-reported functional outcomes using the quick Disabilities of the Arm, Shoulder and Hand score. Thirty-eight patients with nail bed lacerations were treated nonoperatively, and 40 patients were treated with nail bed repair. The average follow-up time was 4.5 weeks in the office. In addition, 1-year evaluation of patients was performed through telephone interview. The patients in the nonoperative group exhibited no statistically significant difference in the calculated risk for nail deformities compared with the nail bed repair group (13% vs 23%, relative risk = 0.58, P = 0.40, 95% confidence interval = 0.42-1.25). There were no significant differences in secondary outcomes or quick Disabilities of the Arm, Shoulder and Hand scores between groups. The authors observed no meaningful difference in the rate of nail deformities in adult patients who underwent nail bed repair compared with those managed nonoperatively.

You Can Handle It: Pediatric Hand Injuries from Toddlers to Teens

As so many of children’s interactions with the world are through their hands, it is no surprise that hand injuries are a common pediatric complaint. Fractures of the hand and wrist account for 2.3% of pediatric emergency department visits, with a peak incidence in the teenage years, coinciding with participation in sports or fights. Hand injuries may be subtle, and appropriate recognition, treatment, and referral are vital for preventing long-term morbidity.After a focused history, providers should inspect for edema, ecchymosis, laceration, or deformity and assess all joints for motor function in addition to active and passive range of motion. The examiner should evaluate sensation and capillary refill, particularly distal to the injury. Any sensorimotor abnormality should raise concern for tendon or nerve involvement. Bony anatomy should be meticulously palpated, with any point tenderness or crepitus evaluated for fracture.The distal phalanx is frequently fractured in toddlers, with peak incidence at 2 years of age. The mechanism is often a crush injury, such as in a doorframe, resulting in a nail bed hematoma, laceration, or amputation. A subungual hematoma with an intact nail plate may be managed with supportive care when it involves less than 50% of the nail surface, or with trephination when it involves greater than 50%. Nail bed lacerations may be anesthetized with a digital block. After nail plate removal and copious irrigation, the laceration should be repaired with absorbable sutures. Glue may be an acceptable alternative but is not appropriate in all situations, particularly a contaminated wound. After repair, the nail fold may be stented open with the native nail, aluminum suture packaging, or nonadherent gauze; however, whether this maneuver improves outcomes awaits ongoing research. Antibiotic drug therapy should be considered for a nail bed laceration with an associated fracture that is contaminated or has significant bone exposure. Tetanus prophylaxis should be administered when indicated.When a nail bed laceration is suspected, radiographs should be obtained: a fracture is present in approximately half of cases, frequently a “tuft fracture” of the distal phalanx. Most fractures can be managed with a finger splint; however, fractures with significant displacement may require future operative management. Seymour fractures are Salter-Harris type I or II fractures of the distal phalanx in which the nail bed becomes entrapped between fracture fragments. These are best visualized on lateral radiographs and should be treated as an open fracture with antibiotics and evaluation by a hand specialist. Complications of Seymour fractures include malunion, nail bed deformity, and osteomyelitis. Treatment within 24 hours is associated with improved outcomes.Amputated fingertips should be wrapped in saline-soaked gauze, placed in a plastic bag, and stored in an ice water slurry, with reimplantation attempted as soon as possible. Amputations that are grossly contaminated, require significant debridement, have exposed bone, or have significant tissue loss warrant evaluation by a hand specialist.Injuries to the middle and proximal phalanxes are associated with athletics and peak between ages 10 and 14 years. Nondisplaced or minimally displaced fractures may be managed with a finger splint or buddy taping. Patients undergoing buddy taping should be counseled on the importance of compliance to avoid skin breakdown and loss of fixation or joint mobility. Painful or unstable proximal phalanx fractures should be placed in an ulnar or radial gutter splint with intrinsic plus positioning (wrist in 20°–30° extension, metacarpophalangeal joints in 70°–90° of flexion, and interphalangeal joints in full extension). A hand specialist should evaluate fractures that are displaced, malrotated, angulated, or involve the physis or joint. A Salter-Harris type II fracture of the proximal phalanx is common, occurring most often in the fifth finger, usually resulting from an abduction injury. Called an “extra-octave fracture,

The Safety of Wide-Awake, Local Anesthesia, No Tourniquet Hand Surgery: Two Cases of Digital Ischemia

PURPOSE: Wide-awake, local anesthesia, no tourniquet (WALANT) hand surgery has gained popularity in recent years. Lidocaine with low-dose epinephrine is used to minimize blood loss and improve patient comfort. WALANT surgery reduces the need for preoperative testing, avoids sedation requirements, allows for patient cooperation during surgery, and decreases cost and procedure time.1 Multiple studies show that local anesthesia with epinephrine is safe to use in the fingers;1,2 however, a few cases of ischemia have been reported.3,4 MATERIALS AND METHODS: We present 2 cases of digital ischemia after WALANT surgery that were successfully reversed with phentolamine. RESULTS: Case 1—A 31-year-old female with rheumatoid arthritis underwent nail plate removal for chronic paronychia performed under a digital block (5 ml of 1% lidocaine with 1:100,000 epinephrine). The patient presented to the emergency room 12 hours later with persistent ischemia and anesthesia. Topical nitroglycerin cream and a warm compress were applied with minimal improvement. Five milligrams of phentolamine in 1 ml of sterile saline was injected at the base of the proximal phalanx with complete resolution of ischemia within 2 hours. At 1-week follow-up, the patient’s finger was perfused. Case 2—A 76-year-old female with multiple medical comorbidities, including cardiac stents (on apixaban) and COPD (on 3 L of home oxygen), underwent trigger finger release under local anesthesia (6 ml of 1% lidocaine with 1:100,000 epinephrine mixed 1:1 with 0.25% plain bupivacaine). She returned to clinic 4 hours later with persistent ischemia. Topical nitroglycerin cream and a warm compress were applied without improvement. 1.5 mg of phentolamine in 1 ml of sterile saline was injected at the level of the A1 pulley. After 90 minutes, there was some improvement but the finger remained ischemic distal to the proximal interphalangeal joint. Another 1.5 mg of phentolamine in 1 ml of sterile saline was injected at the level of the proximal interphalangeal joint with significant improvement. At 10-day follow-up, the patient’s finger was perfused. CONCLUSION: Prolonged digital ischemia after WALANT surgery is rare, but surgeons should counsel patients on warning signs and be prepared for phentolamine rescue when needed. The incidence of epinephrine-induced digital ischemia may increase as WALANT surgery gains popularity. It is mandatory for surgeons performing WALANT procedures to have access to phentolamine. REFERENCES: 1. Al Youha S, Lalonde DH. Update/review: changing of use of local anesthesia in the hand. Plast Reconstr Surg Glob Open. 2014;2:e150. 2. Thomson CJ, Lalonde DH, Denkler KA, et al. A critical look at the evidence for and against elective epinephrine use in the finger. Plast Reconstr Surg. 2007;119:260–266. 3. Zhu AF, Hood BR, Morris MS, et al. Delayed-onset digital ischemia after local anesthetic with epinephrine injection requiring phentolamine reversal. J Hand Surg Am. 2017;42:479 e471–479 e474. 4. Zhang JX, Gray J, Lalonde DH, et al. Digital necrosis after lidocaine and epinephrine injection in the flexor tendon sheath without phentolamine rescue. J Hand Surg Am. 2017;42:e119–e123.

PSS51 - ANALYSIS OF TOPICAL PREPARATIONS FOR TREATMENT OF ONYCHOMYCOSIS IN UKRAINE

Therapeutic options for onychomycosis include oral and topical antifungals. Since topical medicines are used both in monotherapy, and in combination therapy, the aim of this work was to conduct comparative analysis of topical preparations for treatment of onychomycosis included into clinical protocol and State Formulary of Ukraine. comparative analysis of topical medicines included into clinical protocol and State Formulary of Ukraine, 10th edition. Clinical protocol for treatment of onychomycosis (CP) was approved by Ministry of Health of Ukraine in 2012. It recommends three onycholytic preparations with urea to remove infected nail plate, and than to treat a nail bed with either antifungal lacquer or topical preparation with ketoconazole, terbinafine, oxiconazole, miconazole, chlornitrophenol, undecylenic acid, combination preparation with ketoconazole and salicylic acid. The last preparations are listed without indication of a preferred dosage form. State Formulary of Ukraine, 10th (SFU) was approved by Ministry of Health of Ukraine in 2018. SFU also recommends applying antifungals onto nail bed after nail plate removal, but it does not recommend any onycholytic preparations. Furthermore, among 42 topical antifungal preparations included into SFU, only four antifungals are recommended for onychomycosis treatment. These are bifonazole cream, econazole cream, gel and cream with miconazole. Neither ketoconazole nor other topical antifungal preparation listed in CP, except of miconazole, are specified by SFU to be effective for onychomycosis. Antifungal lacquers are not included into SFU at all. There are gaps between CP and SFU. CP should be reviewed in accordance to data of evidence-based medicine. Despite the fact that a new edition of SFU was recently published, it does not include antifungal lacquers, which are broadly used and recommended, for example, by British National Formulary. Thus, it is also necessary to analyze antifungal nail lacquers for making decision about including them into SFU.

Atypical presentation and management of a subungual glomus tumor in the pediatric population

The glomus tumor is a rare vascular neoplasm that accounts for less than 2% of all soft tissue tumors of the hand. This is the first case study to describe the presentation and curative resection of a subungual glomus tumor in the pediatric population. The glomus tumor is classically described as a solitary subungual mass in women aged 30–50 who present with the triad of pain, temperature sensitivity, and point tenderness. However, given an infrequent and inconsistent presentation, the typical time from onset of symptoms to the correct diagnosis is 7 years, resulting in significant functional and cosmetic morbidity for patients. Here we describe an unusual case of a 6-year-old boy who presented with 3 years of pain and progressive, nontraumatic deformity of his left thumb nail. The patient underwent a left thumb nail plate removal, excision of the subungual mass, and nail bed repair. The diagnosis of subungual glomus tumor was confirmed on pathology. Glomus tumors are rare in the pediatric population but should be considered in patients presenting with nail pain and deformity. Keywords: glomus tumor, pediatric hand tumor, subungual

ONYCHOMYCOSES: THE VIEWS OF A DERMATOLOGIST AND A SURGEON

The paper summarizes the data available in the literature on the prevalence of onychomycoses worldwide, their etiology, clinical presentation, and treatment and the authors’ clinical experience. It presents criteria for the systemic and local therapy of onychomycoses and describes nail plate removal methods (indications, contraindications, and complications) in the view of a dermatologist and a surgeon. The current concept of onychomycosis treatment with the local antimycotic naftifine and nail apparatus removal is given.

Management of chronic paronychia

Chronic paronychia is an inflammatory disorder of the nail folds of a toe or finger presenting as redness, tenderness, and swelling. It is recalcitrant dermatoses seen commonly in housewives and housemaids. It is a multifactorial inflammatory reaction of the proximal nail fold to irritants and allergens. Repeated bouts of inflammation lead to fibrosis of proximal nail fold with poor generation of cuticle, which in turn exposes the nail further to irritants and allergens. Thus, general preventive measures form cornerstone of the therapy. Though previously anti-fungals were the mainstay of therapy, topical steroid creams have been found to be more effective in the treatment of chronic paronychia. In recalcitrant cases, surgical treatment may be resorted to, which includes en bloc excision of the proximal nail fold or an eponychial marsupialization, with or without nail plate removal. Newer therapies and surgical modalities are being employed in the management of chronic paronychia. In this overview, we review recent epidemiological studies, present current thinking on the pathophysiology leading to chronic paronychia, discuss the challenges chronic paronychia presents, and recommend a commonsense approach to management.

Fingertip Replantation Without Venous Anastomosis

Replantation of amputated fingertips is a technical challenge, as many salvage procedures fail because no suitable vein in the fingertip is available for anastomosis. In this study, we examined our experience in fingertip replantation in cases without venous anastomosis with our established fingertip replantation treatment protocol. Between August 2002 and August 2010, a retrospective study examined all patients who had undergone fingertip replantation at Chang-Gung Memorial Hospital. All the patients (n = 24) suffered from complete digital amputations at or distal to the interphalangeal joint of the thumb, or distal to distal interphalangeal joint of the fingers. A total of 30 fingertips that were salvaged by microsurgical anastomosis of the digital arteries but not of digital veins were included in this study. On satisfactory arterial anastomosis, a 2-mm incision was made over the fingertip with a number 11 Scalpel blade, and 0.1 to 0.2 mL heparin (5000 IU/mL) was injected subcutaneously around the incision immediately and once per day thereafter to ensure continuous blood drainage from the replanted fingertip. None of the replanted nail plate was removed, and no medical leeches were used. The perfusion of the replanted digits and patient's hemoglobin level were closely monitored. The wound bleeding was maintained until physiologic venous outflow was restored. Of 30 fingertips, 27 (90%) replanted fingertips survived. The average length needed for maintaining external bleeding by chemical leech was 6.8 days (range, 5-10 days). Twelve patients (including a 2-year-old child) received blood transfusions. The average amount of blood transfusion in the 23 adults was 4.0 units (range, 0-16 units) for each patient or 3.29 units (range, 0-14 units) for each digit. A 2-year-old child received 100 mL blood transfusion or 50 mL for each digit. This study showed that a protocol that promotes controlled bleeding from the fingertip is essential to achieve consistent high success rates in fingertip replantation. The protocol is safe and reliable, as it avoids the use of medical leeches and the removal of nail plate from the replanted finger. However, full informed patient consent must include the potential need for transfusion and extended hospital stay.

En Bloc Excision of Proximal Nail Fold for Treatment of Chronic Paronychia

Chronic paronychia is a very recalcitrant dermatosis, which is particularly prevalent in housewives. Medical treatment for this condition is unsatisfactory in a significant number of cases. Surgical approach forms an important part of management, however, this area has received little attention. Various surgical approaches have been tried in the past but a comparative analysis has not been attempted. The present study aims at assessing the efficacy of en bloc excision of proximal nail fold (PNF). Moreover, a comparative analysis has been undertaken to assess whether or not simultaneous nail plate avulsion improves the treatment outcome. Thirty patients of chronic paronychia with nail plate irregularities were randomly divided into two treatment groups (15 patients each). After a detailed evaluation, en bloc excision of PNF with or without nail plate removal was performed. Postoperative measures were advised and the patients were kept under regular follow-up thereafter. Assessment of postoperative complications was also performed. Twelve patients in group I and 13 patients in group II completed the treatment protocol. Of these, 70% of patients were cured in group II (en bloc excision with nail avulsion) whereas only 41% were cured in group I (en bloc excision without nail avulsion). En bloc excision of the PNF is a useful method in recalcitrant chronic paronychia. Simultaneous avulsion of the nail plate improves the surgical outcome. Strict avoidance of irritant exposure is necessary to ensure complete treatment and prevent recurrence.

En Bloc Excision of Proximal Nail Fold for Treatment of Chronic Paronychia

BACKGROUND Chronic paronychia is a very recalcitrant dermatosis, which is particularly prevalent in housewives. Medical treatment for this condition is unsatisfactory in a significant number of cases. Surgical approach forms an important part of management, however, this area has received little attention. Various surgical approaches have been tried in the past but a comparative analysis has not been attempted. OBJECTIVES The present study aims at assessing the efficacy of en bloc excision of proximal nail fold (PNF). Moreover, a comparative analysis has been undertaken to assess whether or not simultaneous nail plate avulsion improves the treatment outcome. METHODS Thirty patients of chronic paronychia with nail plate irregularities were randomly divided into two treatment groups (15 patients each). After a detailed evaluation, en bloc excision of PNF with or without nail plate removal was performed. Postoperative measures were advised and the patients were kept under regular follow-up thereafter. Assessment of postoperative complications was also performed. RESULTS Twelve patients in group I and 13 patients in group II completed the treatment protocol. Of these, 70% of patients were cured in group II (en bloc excision with nail avulsion) whereas only 41% were cured in group I (en bloc excision without nail avulsion). CONCLUSION En bloc excision of the PNF is a useful method in recalcitrant chronic paronychia. Simultaneous avulsion of the nail plate improves the surgical outcome. Strict avoidance of irritant exposure is necessary to ensure complete treatment and prevent recurrence.

Modified Emmet's operation for ingrown nails using the Er:YAG laser

BACKGROUND: Ingrowing nails are a common problem. Standard procedure is surgery according to Emmet (a gycecologist) or Emmert (a surgeon) where postoperative pain, swelling and bleeding are major side effects and traumatic damage of the nail organ is not completely avoidable. Laser surgery may provide an alternative with less tissue damage.METHODS: We compared 138 patients with 212 affected great toe nails (98 males, 40 females) were bloodless Emmet's operation was performed with digital nerve block with 11 patients (12 affected nails) using an Er:YAG laser for atraumatic nail plate removal. Pain was registered by a semiquantitative pain scale (ranging from “zero – no pain” to “10 – maximum pain“). Swelling was scored from “0 – absent” to “3 – severe”. Side effects like bleeding, infection or relapse were registered.RESULTS: Emmet's nail operation: Pain was scored 7.8±3.2 on the operation day (evening), 5.3±3.1 (day 1) and 3.8±4.0 (day 3). Swelling was scored 2.7±1.8 (operation day, evening), 2.1±1.9 (day 1) and 1.3±2.1 (day 3). Wound healing lasted 16.8±3.3 days. The infection rate was 2.4%, i.e. 5 of 212 nails. The relapse rate after 6 months was 12 of 212 nails (5.7%). Spicules were observed in 9 of 212 nails (4.2%). Laser procedure: Pain was scored 8.0±1.9 (operation day, evening), 4.1±1.5 (day 1) and 0.7±2.3 (day 3). The swelling was scored 2.4±1.8 (operation day, evening), 1.5±0.9 (day 1) and 0.9±1.3 (day 3). Wound healing was complete after 12.9±3.5 days. Infections and relapse were not observed. In one case spicules occurred after 5 months. No other side effects were noted.CONCLUSIONS: The modified Emmet's operation for ingrown nails using the Er:YAG laser provides a safe method with increased efficacy that causes less pain and swelling, a faster healing and less complications.

Subungual squamous cell carcinoma

Squamous cell carcinoma of the nail bed is quite uncommon and is often mistaken for other conditions, causing a delay in diagnosis which, once the condition metastasises, can be fatal. We present the case of an 89-year-old man with a 2-year history of a painful lesion under his nail bed in whom histology confirmed subungual squamous cell carcinoma, and who underwent amputation at the level of the interphalangeal joint of his right thumb. It is important that the presence of a rapidly growing tumour suggest the possibility of malignancy, as early and exploratory nail plate removal for the evaluation of any suspicious subungual lesions may allow the avoidance of amputation.

Treatment of Distal Onychomycosis With Avulsion and Topical Antifungal Agents Under Occlusion

<h3>REPORT OF CASES</h3> A 28-year-old man presented with a history of progressive thickening and fragmentation of the left thumbnail over a period of about 1.5 years. Scaling of his left hand previously had been treated successfully with 1% ciclopirox olamine cream applied twice a day for 1 month, but the thumbnail showed no evidence of improvement. He had tried several over-the-counter products for fungus infections of the nail for varying periods of time without success. On physical examination, he showed dystrophic changes of the left thumbnail with subungual hyperkeratosis (<b>Figure</b>, left). The remainder of his skin examination was unremarkable. Hyphae were observed in scales removed from under the left thumbnail, and a culture yielded<i>Trichophyton rubrum</i>. He was unwilling to take oral medication but agreed to be treated with nail plate removal followed by the topical application of an antifungal agent under an occlusive dressing. <h3>THERAPEUTIC CHALLENGE</h3> Distal onychomycosis of

Partial nail plate removal after digital replantation as an alternative method of venous drainage

Partial nail plate removal, systemic anticoagulation, and the application of topical heparin to the exposed nail bed were used to provide and maintain venous drainage for 14 digital replantations in which an arterial repair but no venous repair was done ("artery only" replantation). In each case venous repair was not possible since no vein of an acceptable size could be found either because of a distal amputation level or because an avulsive or crushing injury had damaged the veins in the amputated part. The average operating time per "artery only" replantation was 2 1/2 hours. Ten of the 14 "artery only" replantations survived (71.4%). The active range of motion, sensibility, strength, activities of daily living, and hospitalization for this group of patients were comparable with replantations in which both arterial and venous anastomoses were done.