Unusual nail resection surgery event. Any advice?

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Hi All. In doing a nail resection around 5 weeks ago, something unusual happened with one edge. The other edge proceeded normally, had very little pain and has completed healing.
When using a Black's file to agitate the cauterising chemical into the nail bed, after about 20 seconds, a particular stroke unleashed a strong 'blossoming' flow of blood from the wound. This was difficult to stop and ultimately I used AgNO3 to stem the bleeding. In a separate incident, the patient was bitten by a dog within the next few hours and was on IV broad spectrum antibiotics for a couple of weeks thereafter. Over the intervening weeks, the skin of the proximal nail fold and proximal part of the sulcus has remained swollen and painful, though it is not weeping and there are no gross signs of infection. The patient is a specialist medical doctor and is still taking pain relief for the wound.
Three days ago, I numbed the toe again and took a small additional stripe of nail away - without additional cautery. My thinking here was that: there may have been a small, whispy nail remnant poking into the healing tissue, there may have been a foreign body of some sort involved and, regardless of the mechanism of the problem, removal of some nail to allow the irritated flesh some respite from pressure should be a good thing. I am also aware that the blood flow so early in the two minute cautery process may well mean that the cautery will fail and the nail will regrow. If that were the case, I would have expected the wound to proceed normally for some time and then become a problem as the nail came through. I removed the nail piece but did not prowl around the site of the inflamed area as much as I probably should have, as the patient was becoming agitated.

Checking in today, three days post revision, she reports no change in the pain.

I think that the bleeding must be part of the problem as it would be quite the coincidence to have two unprecedented events occur if unrelated. I estimate that I have done about 1500 - 2000 NWRs without either event before.

So, where to from here? Would ultrasonographic imaging of the wound be useful? Would you adopt a wait and see approach for a bit longer? If not, what would be your next step?

Thanks in anticipation.

 

Be clear, I am not registered any longer, but not withstanding I taught nail surgery for very many years over 4 schools and two hemispheres. With partial nail avulsion, the key issue is not what you take away, it is what you leave behind. If what you plan to leave behind is not viable as a nail then a total avulsion is the answer, not a partial. I have never understood why practitioners are somewhat phobic about undertaking totals; they are easy, a final solution, and incredibly successful.

 

Would be helpful to see the wound but I suspect there is infection - engorged proximal nail fold suggests same. At a minimum get XR to r/o bone infection. Did you swab the wound? Implement broad spectrum antibiotic. I would go back in and release also the proximal nail fold. Agitation or not, you have to do what's necessary. I agree with Bob, a TNA is sensible (you don't necessarily have to cauterize).

As an aside, a TNA can leave some patients with a psychological hang-up. Blogs are filled to overflowing with people searching for a solution to replace that 'missing' toe-nail.

 

Find my answer in this thread
https://podiatryarena.com/index.php?threads/granuloma-después-de.75557/

 

I believe that doing a total removal is usually not needed, and especially when dealing females. There is a huge psychological stigma and aesthetic issue with some people and if a tna can be avoided then why not. In this case though perhaps theres some kind of sub ungual ulceration that needs removal of a larger piece of the nail, if not all of it, to help helaing. I would not phenolise more at this stage though, but removal of a larger section would perhaps help healing and if there is future regrowth you can repeat the nwr where and when needed.
regards
hill

 

STIGMA ASSOCIATED WITH NAIL SURGEY:
I once had a mother of a 13 year old girl bitterly complain to me following a successful and fully healed nwr/pna, (apparently she didnt fully get the idea beforehand) that because the nail now looked slightly narrower, its terrible and the girl will have a very hard time finding a husband because of it. Since then I have always been very careful to explain very well what is involved.
Regards
Hill
www.hillelgluch.com

 

Hi Hill. My thoughts exactly. I did remove an extra piece (described about midway through the initial post) for this reason. TNA isn't required as the nail is really quite normal, patient just has ongoing issues with a sulcus corn. Thx