Overview
Finger nails are used for scratching, in defense, and, more obviously, to pick up small objects. However, the nail also protects the fingertip, contributes to tactile sensation, and plays an important role in the regulation of peripheral circulation. An abnormal nail is both a cosmetic and functional problem in that it catches on objects, particularly cloth, and causes finger pain and damage to the object.
Indications
Nail deformities that require nail removal can occur secondary to anything that causes injury or deformation of the nail bed. This may include infection,[1] self-mutilation, tumor, or trauma.[2]
- Onychocryptosis (ingrown nail)[3]
- Onychogryposis (deformed, curved nail)
- Onychomycosis (fungal infection of the nail)[4] (see the image below)
Candidal onychomycosis in a patient with chronic mucocutaneous candidiasis. Total onychomycosis and paronychia. Image courtesy of Dr Antonella Tosti. - Chronic recurrent paronychia (inflammation of the nailfold)[5] (see the image below)
Typical appearance of paronychia.
Contraindications
- Allergy to local anesthetics (relative contraindication)
- Bleeding diathesis
Anesthesia
Although many procedures like nail removal can be carried out safely under local ring block, some patients may opt for general anesthesia. The following anesthetic procedures are commonly used:
- Local ring block (For more information, see Local Anesthetic Agents, Infiltrative Administration.)
- Procedural sedation (This may be considered but generally should not be required.)
Equipment
- Surgical preparatory supplies
- Syringe, 5 mL
- Needle, 27 gauge (ga)
- Local anesthetic without epinephrine
- Finger tourniquet (eg, rubber band, small Penrose drain, or the finger part of a glove)
- Iris scissors or small Kutz periosteal elevator (nail elevator)
- Straight hemostats (2)
- Nonadherent gauze and tubular gauze dressing
Positioning
- Position the patient supine.
- Abduct the arm.
- Place the hand on an arm extension with the palm facing down.
Technique
- Scrub and drape the finger in a sterile fashion.
- Administer local anesthetic to ring-block the finger.
- Confirm that anesthesia is achieved (wait 5-10 min).
- Use a straight hemostat to firmly secure a finger tourniquet around the base of the finger.
- Insert the blades of curved Iris scissors or a small periosteal elevator beneath the free edge of the nail (hyponychium).
- Gently open and close the Iris scissors blades or gently press the nail bed with the small periosteal elevator.
- Advance proximally in between the nail plate and the nail bed until the instrument reaches the nail fold.
- Take appropriate care to avoid any further damage to the nail bed or overlying nail fold during this process.
- Once the nail is sufficiently separated from the nail bed, it is gently removed by applying firm and steady distal traction using a hemostat.
Pearls
- Apply a tourniquet at the base of the finger to minimize bleeding.
- Take appropriate care to avoid any further damage to the nail bed or overlying nail fold during nail removal.
Complications
- Bleeding
- Infection
- Nail bed injury
- Nail matrix injury
- Paronychial injury
Bonifaz A, Paredes V, Fierro L. Onychocryptosis as consequence of effective treatment of dermatophytic onychomycosis. J Eur Acad Dermatol Venereol. May 2007;21(5):699-700. [Medline].
Forman SB, Ferringer TC, Garrett AB. Basal cell carcinoma of the nail unit. J Am Acad Dermatol. May 2007;56(5):811-4. [Medline].
Lee DY, Lee KJ, Kim WS, et al. Presence of specialized mesenchymal cells (onychofibroblasts) in the nail unit: implications for ingrown nail surgery. J Eur Acad Dermatol Venereol. Apr 2007;21(4):575-6. [Medline].
Finch JJ, Warshaw EM. Toenail onychomycosis: current and future treatment options. Dermatol Ther. Jan-Feb 2007;20(1):31-46. [Medline].
Rigopoulos D, Larios G, Gregoriou S, et al. Acute and chronic paronychia. Am Fam Physician. Feb 1 2008;77(3):339-46. [Medline].
Zook EG, Brown RE. The perionychium. In: Green DP, Hotchkiss RN. Operative Hand Surgery. Vol 2. 3rd ed. Edinburgh: Churchill Livingstone; 1993:1283-97.
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