Chapter 17: Nail Disorders & Surgery Nail Entities Nail AnatomySurgical Nail Procedures

NAIL DISORDERS AND SURGERYNails are excellent indicators of systemic disease and may provide invaluable diagnostic information. The nails are equally sensitive to environmental and physical stimuli and may provide vital clues that indicate toxic exposure and traumatic insult.Owing to the great cosmetic value of the nail, any physical derangement to the structure can bring the patient to your office. You should check for the following nail presentations: discoloration, anonychia, brittleness, hypertrophy, koilonychia, onycholysis, pitting, pterygium, onychomadesis, splitting, striations, nail thinning, ridging, change in nail consistency, change in nail configuration, and nail clubbing.

Nail Entities1. Anonychia: Is the complete absence of one or usually more than one nail. This condition is a rare congenital anomaly.i. Caused by ischemia, frostbite, toxic and infectious states, Raynaud's disease, Darier's disease, lichen planus, subungual neoplasm, fungal infections, psoriasis, and injuries.

2. Paronychia: Is an infection usually accompanying onychocryptosis. Staphlococcus is most common organism. Candida is a common pathogen also. Cultures for bacteria and for fungi are indicated.

3. Beau's Lines: Transverse ridges in the nail plate, 0.1-0.5 mm wide by0.1 mm deep appear in the lunula and progress forward. Beau's lines are a sudden arrest of function of the nail matrix. The width of the Beau's lines are directly related to the duration of the illness.i. Caused by typhus, diptheria, syphilis, malaria, leprosy, influenza, scarlet fever, vascular diseases, diabetes mellitus, hyperthyroidism, ACTH therapy, psroriasis, diffuse alopecia, and exfoliative dermatitis.

4. Clubbed Digits: A characteristic bulbous deformation of the terminal phalanges topped by marked convexity of nails, with the nail becoming hard, lustrous and thick. As the disease progresses, advanced clubbing and angulation of the nail results in Lovibond's angle (> 160 angulation of the nail).i. May be subclassified as hippocratic nails, pulmonary hypertrophic osteoarthropathy, pachydermoperiostosis, or other diseasesii. Can be caused by: congenital heart defects, cirrhosis of the liver, chronic diarrhea, SBE, neoplasms of the lung and emphysema. 80% of clubbing is seen in conjunction with respiratory ailments, but it may be seen in many nonpulmonary acquired and hereditary conditions.

5. Darier-White Disease: Similar to alopecia areata. This condition will cause changes such as red and white longitudinal streaks that run the length of the nail.

6. Eczematous Conditions: Many types of eczematous dermatitis such as

atopic and contact dermatitis frequently affect the nail folds causing damage to the nail matrix. As a result, many changes 'to the nail plate occur, such as Beau's lines, onychorrhexis, subungual hyperkeratosis, and onycholysis. Nail color may change to yellow, green, grey, or black.

7. Onychomycosis: Fungal infections are common, usually caused by dermatophytes. In the cases of monilia and yeast it is reported that onycholysis will develop without destruction of the nail plate. Other diseases mimic this condition, such as psoriasis.i. Distal and lateral onychomycosis: Most common type, caused by T. rubrum, T. mentogrophytes, and E. Floccosum.ii. Proximal subungual onychomycosis: caused by T. rubrum, T. megnini, T. schoenleinii, and T. tonsurans.iii. White superficial onychomycosis: usually T. mentagrophytes and mold fungiiv. Diagnosis by KOH prep and growth on Sabouraud's agar

8. Glomus Tumor: Neoplasia of the arteriovenous shunts (Suquet-Hoyer canals) in the nail beds that constitutes the glomus bodies leads to a purplish tumor that causes extensive pain. The nail bed will appear as a blue-red distortion and the nail plate can have variable distortions. The lesion may be tiny and colorless.

9. Green Nails: Usually caused by a local Pseudomonas infection or Candida albicans. Pseudomonas produces a green pigment called pyocyanin.

10. Keratoacanthoma: This may develop in the nail beds with serious consequences to the nail and subungual structures. The lesion appears suddenly, ulcerated, and both clinically and histologically resembles squamous carcinoma. Underlying bone may be involved.

11. Koilonychia: Means spoon shaped nails and describes a characteristic deformity in the form of a concave shape.i. Occurs with hypochromic anemia, Plummer-Vinson syndrome, thyrotoxicosis, Raynaud's disease, gastrointestinal disorders, nail bed tumors, and syphilis.

12. Leukonychia: A transverse spot or striation porcelain white in color of the nail plate. There are 5 types:i. Leukonychia punctuate (pinhead spot): associated with psoriasis, dyshidrosis, typhus, scarlet fever, measles, arsenic and lead poisoning and microtraumas.ii. Leukonychia striata (transverse): looks like Mee's lines and found with scleroderma.iii. Leukonychia totalis (entire nail): Seen in leprosy, hypochromicanemia, arsenical poisoning, cachexia, and Bart-Pumphrey Syndrome.iv. Partial Leukonychia (nail is all-white but has a distal pink band) As found in Hodgkin's disease, chilblains, metastatic Ca, and leprosy.

v. Longitudinal Leukonychia (longitudinal white stripes): Found in Darier's disease and arsenic poisoning.

13. Lichen Planus: Will result in atrophy of the nail plate and pterygium formation, which is considered pathognomonic for the disease.

14. Malignant Melanoma: Acral lentiginous melanoma is the most dreadful of malignancies found under or around the nails. When the melanotic whitlow is present, there is an elevation of the nail that can be mistaken for glomus tumor, subungual exostosis, or profuse granulation (see chapter 13, Dermatology: Malignant tumors)

15. Mee's Lines: Is an eponym for horizontal striations that appear in the nails as a consequence of arsenic and thallium poisoning.

16. Onychauxis: This is the thickened, elongated, raised irregular nail. The color can be changed from white to a mixture of green, yellow, brown, or black, all of which may obliterate the lunula.i. Can be caused by trauma, fungal infection, nutritional disturbances, circulatory disorders, acute rheumatic fever, secondary syphilis, TB, psoriasis, ichthyosis, eczema, hyperuricemia, RA, venous stasis, hyperglycemia, hyperthyroidism, leprosy, peripheral neuritis, tabes dorsalis, and scleroderma.

17. Onychogryphosis: Is an exaggeration of onychauctic condition.

18. Onychoheterotopia: Means ectopic or abnormal position of the nails.

19. Onychomalacia: Refers to softness of the nails and is synonymous with hapalonychia.

20. Onycholysis: Detachment of the nail bed from the overlying plate creates a space between nail plate and nail bed in which keratin forms. This occurs in numerous conditions:i. Due to trauma, contact dermatitis due to nail polish, cement and topical drugs, fungal infection, Pseudomonas infection, psoriasis, hyperthyroidism, pregnancy, iron deficiency anemia, lichen planus, and many others.

21. Onychomadesis: The shedding of nails from the proximal to the distal free edge. The pathology in this condition involves lesions to the matrix and the hyponychium.i. Due to epilepsy, peripheral neuritis, peripheral thrombosis, embolic occlusions, diabetes mellitus, syphilis, hemiplegia, syringomyelia, and many others.

22. Onychorrhexis: Means the breakage of nails, the nail becoming thin and fragile with exaggerated dermal epidermal subungual sulci.i. Due to hypochromic anemia, hypocalcemia, lichen planus, RA, radiation, arsenic and lead poisoning, leprosy, and syphilis.

23. Onychophagia: Means nail biting.

24. Onychoschizia: The nail becomes very fragile, and as a result, distal splitting of the nail occurs. There are two or more laminations overlying each other. The nail appears multilayered.i. Due to acromegaly, chronic eczema, metabolic acidosis, peripheral nerve lesions, trauma, infectious diseases, hyperthyroidism, and hypochromic anemia.

25. Pterygium Ungium: Overgrowth of the eponychium so that the lunula and much more of the nail plate is covered by a wing (pterygium) of soft tissue.i. Due to scleroderma, Raynaud's disease, vasospastic disorders, leprosy, dermatomyositis and peripheral neuritis.

26. Squamous Cell Carcinoma: This occurs under nail plates usually as a result of a progression from squamous cell Ca in situ (Bowen's disease). It must be differentiated from keratoacanthoma. (see Dermatology section)

27. Splinter Hemorrhages: These are caused by capillary fragility in the longitudinal vessels of the nail bed.i. Due to: scurvy, SBE, CHF, vasculitis, tetanus, hemophilia, and hypoparathyroidism

28. Periungual Fibroma: May be either acquired or congenital.Congenital fibromas are often associated with tuberous sclerosis, a disorder characterized by periungual fibromas, mental retardation, seizures, and adenoma sebaceum. (see Dermatology section)

Nail Anatomy1. The matrix is a stratified epithelium that produces hard keratin. Proximal matrix forms the superior nail and the distal matrix forms the lower nail. 2. Hyponychium is an epithelial layer of the nail bed and really does not produce much nail plate keratin. It does help, however, in subungual debris production.3. Predominantly nail develops from the matrix, but the proximal nail fold, lateral grooves, bed, and hyponychium can all be onychogenic. 4. The nail plate can be separated into 3 zones with predominantly different beginnings. The uppermost layer is generated by the proximal nail fold, the plate by the matrix, and the deepest section of the nail plate is contributed to by the nail folds and bed.5. The nail matrix is found on the proximal slope of the distal phalanx and extends medial and lateral to the phalanx. The germinal matrix extends laterally as far as the width of the nail plate just distal to the lunula and with the same curvature. Proximally it extends to 1 1 /2 to 2 1 /2 times the length of the visible lunula.6. The lunula is a white semi-lunar area corresponding to the anterior matrix.7. The nail bed consists of the hyponychium and corium over the matrix.

Surgical Nail ProceduresNail problems that dictate surgical intervention are abscess, persistent pain, regrowth or spicule development. Chronic nail infections may lead to OM due to the close proximity of the nail and the dorsum of the proximal phalanx.1. Phenol and Alcohol Chemical Matrixectomy:i. Should always do preoperative CBC/Diff and FBS.ii. This procedure has been done in well controlled diabetics, but should be

NOTE* Changes in nail color are markers for disease of blood, endocrine system, cardiovascular and peripheral vascular systems, and toxicity of drugs, chemicals or metals:a. Yellow nails: may suggest Addison's disease or diabetes mellitus b. Blue nails: may be a sign of cyanosis or heavy metal poisoning c Green nails: Pseudomonas infectiond. Black-brown discoloration: may be normal pigmentation, Peutz Jaegher disease (also have brown macules on the palms and soles), Addison's disease, junctional nevus, or melanomae. White nails: may be hereditary, a sign of anemia, fungal infection, Bart-Pumphrey Syndromef. White striae: arsenic poisoning or drug toxicityg. White spots: injury to the nail plate, psoriasish. Alternating white lines with pink nail (Muercke's lines): may suggest anemia, chronic liver disease, nephrotic syndrome, or Darier- White diseasei. Reddish nails (or combination of red/white/brown): may be signs of localized neoplastic disease

avoided in patients with PVD.iii. Phenol and lidocaine are teratogenic and should not be used in the pregnant patient.

2. Sodium Hydroxide Matrixectomy: i. Acetic acid used to neutralizeii. Apply 10% NaOH till capillary coagulationiii. Same criteria apply as for Phenol-Alcohol procedure

3. Frost Procedure:i. For ingrown toenail with "proud flesh" and chronically hypertrophic ungual labiaii. Excise a piece of matrix through an inverse "L" shaped incisioniii. Nail and matrix along the problem labia is excised with the second incisioniv. Closure is with suture after curettement of the phalanxv. Due to the tissue necrosis that occurs, this procedure requires both primary and secondary wound healing, therefore of little advantage over non-cold steel procedures

Figure 1: Illustration of Frost ProcedureClinics in Podiatric Medicine and Surgery: Nail Disorders, Saunders, April 1989, Volume 6:2, with

permission

4. Zadek Procedure: Based on the premise that excision of the nail bed was not necessary in preventing regrowth of the nail, therefore Zadik

NOTE* The following are cold steel procedures. The indications are: chronically recurring ingrown toenail, failed Phenol-Alcohol procedure, chronic hypertrophic ungual labia, subungual exostosis in combination with dystrophic, hypertrophic or mycotic nail, patient in whom chemical or thermal bum is contraindicated (diabetes?), excision and biopsy of nail/nail bed/matrix tissue, in conjunction with bunion procedures, patients who will not comply with postoperative regimen of Phenol-Alcohol procedures, cosmetic reconstruction of deformity, and surgeon's preference.

directed his attention only to the nail matrix.i. The incisions utilized are perhaps this procedures greatest contribution ii. Utilized more for total nail excisions in the lesser digits iii. Not recommended for the difficult onychauxic nail (where nail bed removal may also he necessary)

Figure 2: Illustration of Zadek procedureClinics In Podiatric Medicine and Surgery: Nail Disorders, Saunders, April 1989, Volume 6:2, with permission

5. Kaplan Procedure: The most well documented toenail surgery in the literature. Unlike the Zadek, the Kaplan stressed the need to remove both the nail matrix and nail bed.i. This procedure is indicated for correction of severely onychauxic, mycotic, or chronically deformed or ingrown toenails. It is also the procedure of choice when the former are combined with painful or deforming subungual exostosis or osteochondroma.ii. The original procedure describes an "H" incision carried out at two tissue depths. The proximal half of the "H" includes only the nail matrix and stresses the preservation of periosteal tissue. The distal half of the "H" is carried directly down to the distal phalanx and involves stripping of the nail bed and thus exposing the distal phalanx.iii. A modified Kaplan has been described, whereby, the "H" incision is replaced by the Zadek-type incision. This allows for maximum exposure of the nail matrix area.

Figure 3: Kaplan ProcedureClinics In Podiatric Medicine and Surgery: Nail Disorders, Saunders, April 1989, Volume 6:2, with permission

Figure 4: Wound closure for Winograd ProcedureClinics In Podlatric Medicine and Surgery: Nail Disorders, Saunders, April 1989, Volume 6:2, with

permission

6. Winograd procedure: Dr. Winograd was the first to describe a linear incision into the posterior nail fold with excision and curettage of the nail matrix tissue. The incision he discribed is the same used today.i. Contrary to popular belief, the most important component of wedge resection is wound closure and not whether the entire matrix is encompassed within the width of the tissue ellipse.ii. When a modified Winograd is considered, 3 preoperative components must be considered: must be sure that an adequate amount of soft tissue exists for good

wound closure. the length of the ellipse must be at least 3 times the width wound closure is by primary intention (preferably)

7. Suppan Procedure:i. Frees the eponychial fold and removes the nail ii. Visualizes the nail matrix proximallyiii. Cut the lateral borders and the anterior borders iv. Hold tag and remove the proximal attachment v. Curette down to bone into the lateral cul de sac

8. Complications From Nail Surgery:a. Recurrenceb. Excessive drainagec. Excessive bleedingd. Poor technique and excessive tissue destruction e. Infectionf. Exuberant granulation tissueg. Insufficient amount removedh. Soft tissue migration upward to the dorsum of the toe