Nail Avulsion Surgery: Indications and Complications

Introduction:

Nail avulsion is the detachment of the nail plate from the adjacent surrounding tissues. This procedure is carried out either surgically, non-surgically, or through a chemical approach on the nail. These procedures are carried out either for diagnostic purposes or in any diseased conditions of the nails (nail pathology). The surgical technique for nail avulsion is carried out either from the distal end or from the proximal nail fold. The distal approach is the commonly used method in which the nail plate is relieved from the nail bed at hyponychium. If the approach is from the proximal side of the nail fold, it involves the complete separation of the nail. Chemical nail avulsion is done by application of urea-based ointments.

What Is Meant by Nail Avulsion?

Losing a toenail or fingernail due to an injury is meant to be avulsion. The nail can be completely or partially eliminated from the affected area after an injury. The doctor may treat it by removing the nail or repairing the nail bed. It usually takes about four to six weeks to heal. During this time, the person can carry on with their regular activities. When the toenail is avulsed, the person can walk and carry on their daily activity. But swimming and sports activities need to be avoided as they can enhance the chances of getting injured again.

What Are the Indications of Nail Avulsion?

Surgical removal of the nail is indicated when the affected nail is causing manifestations and the condition is not getting better by any other means, like using medications. Nail avulsion is usually indicated for diagnostic purposes or in any nail pathologies.

1) Diagnostic Purpose:

• Biopsy: In certain conditions like psoriasis, lichen planus, and nail tumors, surgical procedures are carried out on the nail bed to remove a small portion of the diseased nail. This surgically removed nail portion is sent to the lab for diagnostic purposes.

2) Nail Pathologies:

• Tumors: Nail surgeries are carried out in certain nail tumors like onychomatricoma (tumor of the nail matrix) and glomus tumors (painful subcutaneous tumors occurring beneath the nail bed). Various other tumors like pyogenic granuloma, fibrokeratoma, and melanoma cancers also need surgical nail avulsions.

• Onychomycosis: Fungal infections of the nails are called onychomycosis. Fungal infections are common among toenails when compared to fingernails. These fungal infections do not cause any serious conditions, but patients might experience pain and worry about the appearance of their nails. The nails appear thickened, brittle, and fractured. In such instances, surgical removal of the affected nail is advised.

• Onychogryphosis: It is otherwise called a ram’s horn nail. It is usually congenital and seen in people with psoriasis and poor maintenance, as well as in people wearing very tight footwear. The nails appear cloudy with yellowish brown thickening of the nail plate. Nails appear longer than usual with increased bending of the nails.

• Onychocryptosis: An ingrown toenail is otherwise called onychocryptosis. This is a very painful condition because the toenails grow into the skin along the sides of the toes. It is commonly seen on the outer surface of the bigger toe, where the ingrowth can be seen on both sides of the toes.

• Nail Dystrophy: It is also called onychodystrophy. Unusual changes in the shape, color, and growth of both fingernails and toenails are called nail dystrophy. Nail dystrophy mainly occurs because of trauma or any infections to the nails. Underlying systemic diseases like heart, lung, and kidney can also cause nail dystrophy. Certain chemotherapeutic drugs used in cancer treatment also cause dystrophy of nails.

• Chronic Paronychia: It is a chronic inflammatory disorder of the nails (both toes and fingers) and is usually seen in housewives. Nails appear reddened, swollen, tender, and present with recalcitrant (non-responsive to treatment) dermatoses. Chronic paronychia can be treated by complete excision of the proximal nail fold followed by total or partial nail avulsion surgery.

• Omega Nails: Also called pincer nails or trumpet nails, the side edges of the nails slowly grow inwards, pressing the nail bed and the underlying skin (dermis). This is more commonly seen in toenails when compared to fingernails and is asymptomatic. Chemical nail avulsion with 40 % urea is more effective in treating omega nails rather than surgical avulsion.

• Retronychia: A condition of reverse nail growth into the proximal nail fold. This condition is usually underdiagnosed, and surgical avulsion of the nail plate is suggested as a curative option.

• Warts: Warts are nothing but nail tumors seen in children and adolescents. Periungual warts are mainly caused due to HPV 1,2,4 (human papillomavirus). Frequent nail biting and maceration (prolonged moisture contamination of the skin) also favor periungual warts.

What Are the Contraindications of Nail Avulsion Surgeries?

Nail surgeries are contraindicated in people suffering from certain disorders like:

• Diabetes mellitus.

• Bleeding disorders (hemostatic disorders).

• Collagen vascular disorders (inflammatory conditions of the connective tissues).

• Peripheral vascular disorders (blood circulation disorders occurring outside of the heart).

These are considered relative contraindications but not absolute contraindications.

What Are the Complications of Nail Avulsion Surgery?

Secondary bacterial infections are the most commonly seen complications after a nail avulsion. Complications could also be due to damage to the nail matrix resulting in permanent nail deformity. Other complications involve:

• Allergic contact dermatitis.

• Nail regrowth.

• Nail deformity.

• Prolonged wound healing.

• Pain and swelling.

• Infection and hematoma formation.

• Allergy to anesthesia.

What Is the Prognosis of Nail Avulsion Surgery?

Post-operative care is the crucial step in the prognosis of the surgery. A highly absorbent, non-adherent dressing is given for the first 24 hours, and this dressing should be removed by soaking it in hot water. Every day, the wound should be cleaned with a povidone-iodine solution to promote healing. Rest is advised to the patient, and the operated area should be kept in elevation to avoid pain and swelling. Usually, it takes around two weeks for the patient to get back to daily routine activities.

Conclusion:

The doctor must clearly understand the anatomy of the nail before carrying out the nail avulsion surgery to prevent injury to the nail matrix. The conventional method (total removal of nails) has been replaced by partial nail avulsion surgeries due to lessened post-operative complications. The prognosis of the nail surgery avulsion depends upon careful patient selection, following strict sterilization protocol, and performing surgery without causing any damage to the matrix and nail folds.