Nail Avulsion Procedures

Steps for partial nail avulsion
  1. Perform exam/obtain consent
  2. Hallux block
    1. Dorsomedial - proper digital branch of medial dorsal cutaneous nerve
    2. Dorsolateral - proper digital branch of medial terminal branch of deep peroneal nerve
    3. plantarmedial - proper digital branch of medial plantar nerve
    4. plantarlateral - proper digital branch of medial plantar nerve
  3. Free soft tissue with elevator (concave side against the nail plate)
    1. start proximally under eponychium all the way to extensor ridge
    2. move to phalanx condyle
    3. go deep to the nail plate, making way to extensor rdige
  4. English anvil nail nipper to divide the plate
    1. insert bottom end as far as you can go to take as big of bite as possible
    2. cut back to extensor ridge
  5. Use hemostat to grab nail plate and twist away
  6. Phenol (if you're using)
    1. insert cotton tip applicator as far proximally as possible
    2. rotate towards remaining nail
    3. leave in for 1 minute
    4. repeat 2 more times
    5. copiously irrigate with alcohol or saline


Nail anatomy


Modifiers TA, T1-T9

Modifier
Brief Description
TA
Left foot, great toe
T1
Left foot, second digit
T2
Left foot, third digit
T3
Left foot, fourth digit
T4
Left foot, fifth digit
T5
Right foot, great toe
T6
Right foot, second digit
T7
Right foot, third digit
T8
Right foot, fourth digit
T9
Right foot, fifth digit

-His right hallux was anesthetized using 5 cc of 1.0% lidocaine following alcohol prep.
-A tourniquet and small hemostat were used to achieve hemostasis. A Freer elevator was first used to free the nail from the medial nail border. The Freer elevator was also utilized to free up the proximal nail border, extending distally to the extensor ridge of the distal phalanx. An English anvil nail nipper was used to remove a little over 1/3 of the hallucal nail. A mosquito hemostat was used to remove the offending nail. A nail curette was utilized to ensure the nail spicule was removed, to which additional offending nail was removed using an English anvil.
-Phenol was then applied to his nail matrix distally (3 times for 45 seconds). His nail bed was then irrigated using saline to flush the phenol from the affected area.
-Triple antibiotic ointment was applied to the treated area and the right hallux was dressed with 2 by 2 gauze, 2 inch Kling, and 1 inch Coban without incident.