Nail Procedures: Best Practices and Updates Edward J. Mayeaux, Jr., MD, FAAFP ACTIVITY DISCLAIMER The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP. This CME session is supported in the form of disposable supplies (non-biological) to the AAFP from Bovie Medical Corp. DISCLOSURE It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose. The content of my material/presentation in this CME activity will include discussion of unapproved or investigational uses of products or devices as indicated: 40% urea ointment for nail avulsion Edward J. Mayeaux, Jr., MD, FAAFP Professor and Chair, Department of Family and Preventive Medicine/Professor of Obstetrics and Gynecology, University of South Carolina School of Medicine, Columbia Dr. Mayeaux lives and practices in Columbia, South Carolina. He has received the American Society for Colposcopy and Cervical Pathology (ASCCP) Award of Merit three times and has also received numerous faculty teaching awards. He focuses on women's health and skin diseases, noting that the most important trends in the field are the rise and fall of methicillin-resistant Staphylococcus aureus (MRSA); changes in Pap test recommendations and follow-up; and changes in human papillomavirus (HPV) testing recommendations. Dr. Mayeaux considers keeping up with the rapidly changing knowledge base in medicine to be family medicine's most critical challenge. Other professional interests include health care quality, preventive medicine, and returning joy to medical practice. Learning Objectives 1. Demonstrate common methods used for nailbed surgery and repair. 2. Illustrate the steps used to treat ingrown nails and nail abnormalities. 3. Prepare assessment and treatment plans for different patient populations who may require various nail procedures. 4. Assemble appropriate tools for nail procedures. Nails - Introduction • Protects distal phalanges • Increases mechanical traction • Enhances fine touch • Cosmesis • Surgical methods may be needed to diagnose and treat nail problems Courtesy of Dr. E.J. Mayeaux, Jr. Normal Nail Anatomy • Nail plate – Hard, flexible – “The nail” – Keratinized sq. cells – Borders - proximal and lateral nail folds – Longitudinal grooves on dorsal surface Haneke E. Surgical anatomy of the nail apparatus. Dermatol Clin 2006; 24:291. Courtesy of Dr. E.J. Mayeaux, Jr. Normal Nail Anatomy • Nail bed – Highly vascular – Longitudinal ridges - interdigitates Courtesy of Dr. E.J. Mayeaux, Jr., M.D. with nail bed – Borders lunula, lateral nail folds, and hyponychium Haneke E.Dermatol Clin 2006; 24:291. Normal Nail Anatomy • Nail matrix – Germinal center – Proximal produces dorsal nail • 80% of plate - causes curvature – Proximal nail fold covers most of matrix – Visible part is lunula – Melanocytes absent in nail bed Courtesy of Dr. E.J. Mayeaux, Jr., M.D. Haneke E.Dermatol Clin 2006; 24:291. Normal Nail Anatomy • Anterior ligament attaches distal phalanx to the hyponychium • Posterior ligament attaches matrix and proximal fold to distal phalanx Courtesy of Dr. E.J. Mayeaux, Jr., M.D. Haneke E.Dermatol Clin 2006; 24:291. Digital Ring Block • Anesthesia for variety of nail procedures • Lidocaine without epinephrine? – Doesn’t matter in most people • Use 27-30 gauge needle, HCO3 and slow injection to minimize pain • Anesthesia in 5 to 10 min • Luer lock syringe Jellinek NJ, Vélez NF. Dermatol Clin. 2015 ;33(2):265-71. Lidocaine + 1:200,000 Epinephrine • Comprehensive medical literature reviews of >10,000 surgical procedures and large observational studies have failed to find any reports of gangrene or major ischemic complications attributable to lidocaine with epinephrine 1-5 – Doppler study - vasoconstrictive effects resolve within 90 minutes 6 • Epinephrine with lidocaine leads to faster onset and longer duration of anesthesia without negative vascular sequela 7 1. Denkler K. Plast Reconstr Surg 2001; 108:114. 2. Muck AE, et al. Ann Emerg Med 2010; 56:270. 3.Chowdhry S, et al. Plast Reconstr Surg 2010; 126:2031. 4.Lalonde D, et al. J Hand Surg Am 2005; 30:1061. 5.Thomson CJ, et al. Plast Reconstr Surg 2007; 119:260. 6. Altinyazar HC, et al. Dermatol Surg 2004; 30:508. 7. Krunic AL, et al. J Am Acad Dermatol 2004;51:755-9. Digital Ring Block • Prep • Raise a weal? • Direct needle toward plantar surface on medial side • Inject 1-2 cc on return The Essential Guide to Primary Care Procedures 2nd ed. 2015 Courtesy of Dr. E.J. Mayeaux, Jr. Digital Ring Block • Without leaving skin, redirect across top of digit • Inject 1-2 ml on return The Essential Guide to Primary Care Procedures 2nd ed. 2015 Courtesy of Dr. E.J. Mayeaux, Jr. Digital Ring Block • On the lateral side, direct needle toward plantar surface • Inject 1-2 cc on return The Essential Guide to Primary Care Procedures 2nd ed. 2015 Courtesy of Dr. E.J. Mayeaux, Jr. Digital Ring Block • For smaller digits, a single injection hole Courtesy of Dr. E.J. Mayeaux, Jr. may be used to inject down both sides • Tenting the skin makes entry of needle easier Courtesy of Dr. E.J. Mayeaux, Jr. The Essential Guide to Primary Care Procedures 2nd edition. 2015 Digital Ring Block • Insert the needle to the bone, and infuse Courtesy of Dr. E.J. Mayeaux, Jr. anesthetic • Angle the needle and inject volarly & dorsally • Repeat this technique on the opposite side Courtesy of Dr. E.J. Mayeaux, Jr. Wing Block Procedure • Hold the needle perpendicular to the long axis of the digit and at 45 degrees to the plane of the hand • Insert the needle 3 mm proximal to the proximal nail fold • Inject the anesthetic along the proximal nail fold • Slowly withdraw the needle and redirect it toward the lateral nail fold • May need to performed on the opposite side of the nail Jellinek NJ, Vélez NF. Dermatol Clin. 2015 ;33(2):265-71. Courtesy of Dr. E.J. Mayeaux, Jr. Nail Removal • Ingrown toenail (Onychocryptosis) – Most common reason – Improper fit of nail plate in lateral groves – Significant discomfort – Great toe usually – Foreign body reaction – appears infected • Abx do not change outcomes Reyzelman AM, et al. Arch Fam Med 2000; 9:930. Ingrown Nail • Onychocryptosis or Unguis incarnates • Commonly treated in primary care 1 • Periungual skin of lateral nail folds is traumatized by adjacent nail plate, resulting in an inflammatory foreign body reaction. 2 • Painful, draining, foul-smelling lesion and hypertrophy of the involved folds. Courtesy of Dr. E.J. Mayeaux, Jr. 1. Barreiros H. An Bras Dermatol. 2013 Nov-Dec;88(6):889-93. 2. Eekhof JAH, Cochrane Database of Systematic Reviews 2012.. 23 Risk Factors • Behavioral risk factors • Physiologic risk factors – Improper nail plate trimming – Plantar hyperhidrosis – Wearing constricting – Diabetes footwear – Obesity – Repetitive toe trauma – Cardiac disorders* • Anatomic variations – Renal disorders* – Disproportionate plate width – Thyroid disorders* – Excessive nail plate *Predisposes to lower extremity thickness and curvature edema – Rotation of the distal phalange – Heavy nail folds 1. Barreiros H, et al. An Bras Dermatol. 2013 Nov- – NOT wider nail folds and Dec;88(6):889-93. 2. Pearson HJ, J Bone Joint Surg Br. thinner, flatter nails 1987;69(5):840-842. Trimming Nail Plates No! No! No! Yes! Courtesy of Wikipedia Commons (Public Domain) Palliative Measures • Elevation of nail edge • Selective trimming • Frequent soaking • Oral or topical abx • Loose footwear • Resolution rare without removal Ingrown Toenails Clinical Stages I – mild II - moderate III - severe Nail-fold swelling, Additional finding of Chronic inflammation, edema, erythema, and inflammatory granuloma the formation of pain (with pressure), tissue and seropurulent epithelialized resulting from the nail discharge; infection; and granulation tissue, and plate puncturing the skin sometimes ulceration of sometimes marked nail- the