lumbar puncture BY

ingrown nail removal

BYDR. J.I. NWAPIOUTLINEOverviewIndicationsContraindications (Relative/Absolute) Procedure/Pitfalls Equipment Preparation operative procedure Pitfalls/Complications

overviewIngrown nails, or onychocryptosis, is a common problem encountered in family practice.Individuals with ingrown nails often present in the second or third decades of life with pain, drainage, and difficulty walking. Many causes have been associated with the development of ingrown nails (see below). All of these causes alter the normal fit of the nail plate in the lateral groove, resulting in a foreign body reaction that produces oedema, infection, and granulation tissue. Many ingrown nails exhibit a laterally pointing spicule of nail that digs into the lateral tissue.

overview CONT.Improperly trimmed nails or torn distal nailsHyperhidrosisExcessive external pressure from improperly fitting footwear or poor stance and gaitTrauma to the nail unitSubungual neoplasms or skeletal abnormalities Diabetes mellitus Obesity Nail changes of the elderly, including onychogryphosis and onychomycosisOverview CONT.Three stages have been described for the progression of ingrown nails. In stage I, the lateral nail fold exhibits erythema, mild oedema, and pain when pressure is applied. In stage II, individuals experience increased symptoms, drainage, and infection. Stage III is characterized by magnified symptoms, the presence of granulation tissue in the lateral nail fold, and lateral wall hypertrophy.

Management Options for Ingrown nailsWarm water soaksCotton-wick insertion in the lateral groove cornerDebridement (debulking) of the lateral nail grooveSilver nitrate cautery to the hypertrophied lateral nail tissueComplete nail avulsionPartial nail avulsionWedge resection of the distal nail edgePartial nail avulsion with:Phenol matricectomySodium hydroxide matricectomyLaser matricectomyElectrosurgical matricectomySurgical excision of nail plate, nail bed, and matrixOverview - managementSoaks, topical or systemic antibiotics, and cotton wick insertion in the lateral nail groove have all been used for grade I disease. Surgical intervention is advocated for grade II and more often for grade III disease. Because ingrown nails represent an abnormal lateral nail groove, removal of more than the lateral one fourth of the nail is unnecessary.High recurrence rates are associated with these simple nail excision proceduresMGT. CONT.Matricectomy of the lateral nail matrix is required to permanently ablate lateral nail-forming tissue and to create a new lateral nail fold. Chemical matricectomy can be performed with sodium hydroxide or more commonly with phenol. Phenol produces adequate nail bed ablation, but it is associated with a pungent odour, lateral nail fold damage, excessive wound discharge, and infection.Overview managementElectrosurgical ablation of the nail bed is a highly successful alternative that produces less discharge. Special matricectomy electrodes with one coated side can be used to avoid injury to the overlying normal tissue of the proximal nail fold (i.e., cuticle) while ablating the nail bed. Laser matricectomy is another option, but it is less attractive because of the high capital and upkeep costs for most primary care practices.Overview managementThe granulation tissue produced by the foreign body reaction can produce lateral wall hypertrophy. Because this tissue is abnormal, many physicians advocate removal at the time of nail surgery. Removal of lateral wall hypertrophy can be accomplished with scalpel excision or with electrosurgical excision or ablation. Tissue removal can produce a scooped-out defect in the lateral tissue at the time of surgery. This defect fills in over several weeks as the remaining normal lateral tissue grows to the newly formed lateral nail edge.indicationsIngrown nail, grade II or grade IIIRELATIVE CONTRAINDICATIONS

Diabetes mellitusPeripheral vascular disease, especially if digital ischaemia existsCoagulopathy or bleeding diathesisUncooperative patient

equipmentNon-sterile Tray for the ProcedurePlace the following items on a nonsterile drape covering the Mayo stand:Nonsterile gloves10-mL syringe filled with 1 percent lidocaine (Xylo-caine), and a 30-gauge needle4 4-inch gauze soaked with povidone-iodine solution1 to 2 inches of 4 4 gauzeFenestrated drapeIris scissorsBandage scissors2 straight hemostatsSterile rubber band (if desired)Nail splitter (if desired)Monsel's solution and cotton-tipped swabs (if desired)

Equipment cont.Tray for Post-procedure DressingUnfolded 4 4 gauze (for wrapping the toe)Antibiotic ointmentRoll of 1-inch tapeSurgical sponge slipper to wear over the bandaged toe (cut in a 1-inch strip to cover the surgical site)

Procedure Description

The patient is placed in the supine position, with the knees flexed (foot flat on the table) or extended (foot hanging off the end of the table).The physician wears non-sterile gloves.The toe is prepared with povidone-iodine solution. A standard digital block is performed with 1 percent lidocaine (without epinephrine), using a 10-mL syringe and a 30-gauge needle. About 2 to 3 mL of lidocaine on each side of the toe is usually sufficient for adequate anesthesia. A wait of 5 to 10 minutes allows the block to become effective.

Procedure description cont.Use a sterile rubber band around the base of the toe for a dry operative field. A clean, unused rubber band can be placed in a sterilization pouch and put through an autoclave. Alternatively, pressure to the sides of the toes during the procedure can reduce bleeding. A tourniquet should be used for the shortest possible time only.The toe is rewashed with surgical solution, and a fenestrated drape is placed over the foot, with the involved toe protruding through the drape. A nail elevator or the closed tips of iris scissors are slid under the cuticle to separate the nail plate from the overlying proximal nail fold.

16Procedure descriptionThe lateral one fourth or one fifth of the nail plate is identified as the site for the partial lateral nail removal. This area is usually where the nail curves down into the toe. Use a nail splitter or bandage scissors, cutting from the distal (free) end of the nail straight back (proximally) beneath the proximal nail fold. A straight, smooth, new lateral edge to the nail plate is created. When the scissors cut through the most proximal edge of the nail beneath the cuticle, a give can be felt.

Normal nail anatomy

Lateral nail avulsion

Procedure descriptionGrasp the lateral piece of nail with a haemostat, getting as much nail plate as possible into the teeth of the instrument. The lateral nail plate is removed, in one piece if possible, by rotating the fragment outward toward the lateral nail fold, while pulling straight out toward the end of the toe.If the lateral nail plate breaks, the remaining nail is re-grasped and pulled out. No fragment of nail plate should remain under the proximal nail fold.aftercareAntibiotic ointment is applied, a bulky gauze dressing is placed, and the patient's foot is put in a disposable surgical slipper. The patient should apply antibiotic ointment daily until healing is complete. The patient should be given the instruction sheet and told to take ibuprofen (Motrin) and acetaminophen (Tylenol) for postoperative pain. Daily cleansing with warm water is encouraged, and strenuous exercise is discouraged for at least one week.aftercare

Do pathologic evaluation when an abnormal growth or suspected malignancy is encounteredIf increasing pain, swelling, redness, or drainage develop, the toe should be evaluated for infection. Infection is common after ingrown toenail removal. Early intervention with oral antibiotic therapy can be highly effective in preventing infectious complications.Incomplete matricectomy can allow a spicule of new nail to grow laterally, interfering with the newly created lateral nail groove. A second procedure may be required to obliterate the lateral spicule if inadequate matricectomy is performed during the first procedure.

PitfallsProlonged Application of the Tourniquet Can Lead to Distal Toe Ischaemia. Patients with distal toe ischemia usually present with duskiness, poor healing, occasional ulceration, and even necrosis of the affected digit. Ingrown toenail removal can be performed without a tourniquet, but it is easier with a bloodless surgical field. If a tourniquet is used, it should be removed as soon as possible.PitfallsThe Patient Returns After Two Weeks With a Swollen, Red, Inflamed Toe. Infection is not unusual after the procedure, and oral antibiotics can be liberally administered.Some physicians routinely prescribe antibiotics for a few days after the procedure. Management of aggressive infection can reduce the chance of patients developing the rare complication of osteomyelitis.

PitfallsThe Patient Complains That the Surgery Did Not Get Rid of the Ingrown Nail. If inadequate matricectomy is performed, a spike of nail can regrow along the new lateral nail fold. This laterally growing piece of nail creates another inflammatory reaction in the lateral toe, necessitating a second procedure. The physician must make sure that the lateral horn matrix cells under the proximal nail fold are adequately ablated the first time.

PitfallsThe Nail Bed Is Lacerated When the Nail Is Cut With the Bandage Scissors. The physician must cut with the smallest blade of the scissors beneath the nail. The tips of the scissors should be slightly angled upward to avoid lacerating the fragile nail bed beneath the nail plate. Usually, bleeding from superficial lacerations is controlled by electrocautery. Deep lacerations may require suture repair and removal of additional nail.

PitfallsThe Patient Is Surprised by the Postoperative Appearance of the Toe.Patients should be reminded that the procedure will permanently narrow the nail. In addition, the concavity left when the lateral granulation tissue is removed can be a shock, but patients can be reassured that the tissue will gradually fill in.

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