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Subject: Nail Avulsion and Matrixectomy
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Syringe (3 mL or 5 mL) with long (1- or 1.5-inch) 25- or 27-gauge needle
Local anesthetic without epinephrine
Narrow periosteal elevator (nail elevator)
Sterile scissors with straight blades (or nail splitter)
Two straight hemostats
Sterile gauze and tubular gauze dressing
Topical antibiotic ointment
Phenol solution (88%) and a radiofrequency electrosurgical unit with a Teflon-insulated matrix tip or a low-frequency unit with a needle tip (if performing a matrixectomy)
Onychocryptosis (ingrown nail), especially stage II or stage III
Onychomycosis (fungal infection of the nail) when pressure on the nail causes pain)
Onychogryposis (deformed, curved nail)
Peripheral vascular disease, especially if digital ischemia exists.
Coagulopathy or bleeding diathesis.
Overt bacterial infection of the operative site is a relative contraindication to matrixectomy. However, most “infected” ingrown nails do not contain bacteria; they have a sterile inflammatory reaction to the trauma.
PEARL: Some physicians prefer to place a tourniquet (a rubber band or Penrose drain placed around the digit and held with a hemostat) in an attempt to limit bleeding during the procedure. There is no evidence this actually works, and many providers perform the procedure without this step with identical outcomes.
PEARL: When checking the patient’s ability to sense pain in the digit, ask them if they “feel pain,” not if they “feel anything.” Remember, local anesthetics do not block touch receptors.
PITFALL: If using a tourniquet, avoid pulling the rubber band too tightly and damaging the tissues. Limit the amount of time that the tourniquet is placed. It is advisable to withdraw the tourniquet after 10 minutes of application to limit vascular injury from interrupted blood flow to the digit.
PITFALL: Avoid damaging the nail bed when cutting the nail plate. If the scissors are used, the blade placed beneath the nail plate can traumatize the nail bed. Advance the scissors by cutting just with the tips of the scissors, and angle the tips of the scissors upward away from the nail bed.
PITFALL: Do not cut the ventral fold, because this area may be slow to heal.
PITFALL: Grasp as much of the lateral nail in the hemostats before attempting withdrawal. If just the end of the nail plate is grasped, the nail frequently breaks on removal.
PITFALL: Avoid prolonged activation of the electrode against the nail bed. Prolonged burning can damage the deep tissues (i.e., extensor tendon insertion beneath the nail bed) and cause excessive time (months) for healing.
PITFALL: If the lateral horn of the matrix is not destroyed, a new spicule of nail will grow into the new lateral nail fold, with recurrence of symptoms in the months after the procedure.
Infections (treat with soaks and appropriate antibiotics).
Regrowth of nail and return of symptoms. (The regrowth rate following phenol cauterization is 4% to 25%; for radiofrequency, <5%.)
Permanent loss of nail plate (mainly with bilateral matrixectomy).
Damage to underlying structures due to excessive application of electrosurgical matrixectomy.