Nail Removal

Nail Removal

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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.

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, as in the following [2, 3, 4] :

Onychocryptosis (ingrown nail) [5]

Onychogryposis (deformed, curved nail)

Onychomycosis (fungal infection of the nail) [6] (see the image below)

Chronic recurrent paronychia (inflammation of the nailfold) [7] (see the image below)

Contraindications are as follows:

Allergy to local anesthetics (relative contraindication)

Bleeding diathesis

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 includes the following:

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

Position the patient supine.

Abduct the arm.

Place the hand on an arm extension with the palm facing down.

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.

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 can include the following:

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. 2007 May. 21(5):699-700. [Medline].

Forman SB, Ferringer TC, Garrett AB. Basal cell carcinoma of the nail unit. J Am Acad Dermatol. 2007 May. 56(5):811-4. [Medline].

Yılmaz A, Çenesizoğlu E. Partial matricectomy with cryotherapy in treatment of ingrown toenails. Acta Orthop Traumatol Turc. 2016. 50 (3):262-8. [Medline].

Kim M, Song IG, Kim HJ. Partial Removal of Nail Matrix in the Treatment of Ingrown Nails: Prospective Randomized Control Study Between Curettage and Electrocauterization. Int J Low Extrem Wounds. 2015 Jun. 14 (2):192-5. [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. 2007 Apr. 21(4):575-6. [Medline].

Finch JJ, Warshaw EM. Toenail onychomycosis: current and future treatment options. Dermatol Ther. 2007 Jan-Feb. 20(1):31-46. [Medline].

Rigopoulos D, Larios G, Gregoriou S, et al. Acute and chronic paronychia. Am Fam Physician. 2008 Feb 1. 77(3):339-46. [Medline].

Zook EG, Brown RE. The perionychium. Green DP, Hotchkiss RN. Operative Hand Surgery. 3rd ed. Edinburgh: Churchill Livingstone; 1993. Vol 2: 1283-97.

Rahi K Yallapragada, MBBS, MRCS, FRCS(T&O), MCh(Orth) Specialty Doctor, Trauma and Orthopaedics, Lister Hospital, UK

Rahi K Yallapragada, MBBS, MRCS, FRCS(T&O), MCh(Orth) is a member of the following medical societies: Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of England

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

The authors and editors of eMedicine gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.

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