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Nail Surgery

Discussion in 'General Issues and Discussion Forum' started by alanpackwood, Feb 20, 2012.

  1. alanpackwood

    alanpackwood Member


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    Advice on Nail Surgery

    I require some advice regarding a nail surgery I carried out, having spoken with colleagues and checked Podiatry Arena the problem is either an allergic reaction to phenol or rapid healing. As there has been no leakage from the site of the nail surgery, 4 weeks since surgery was carried out, the most likley problem is rapid healing. However, I have some specific questions which I would be grateful for your thoughts on. Details of the patient etc are below:

    Patient Details: The patient is a 12 yr old female who presented with onychocryptosis of the left 1st medial nail plate. There was hyper-granulation tissue present and local infection, the patient had been prescribed anti-biotics for this infection by her GP.

    Medical History: There was no medical history nor medication being taken and no contra-indications for either the LA or the nail surgery to go ahead.

    Procedure: PNA was carried out using phenol, there were no complications during the nail surgery.

    The patient was brought back for a number of post surgery checks, it was noted the left hallux still looked infected as it was swollen and red but no discomfort was being felt. The patient was referred back to the GP for C&S but this came back negative, no bacterial infection was present. The patient reported that there had been no leakage from the site of the PNA as would be expected.

    If this is rapid healing, I am aware advice on Podiatry Arena has indicated the site of the PNA should be reopened to allow release of the fluid. I am reluctant to do this as the patient was quite distressed during the surgery and I am keen to avoid further distress if possible, with this in mind please consider the following:

    If I leave the toe alone but continue to monitor would it be reasonable to expect the problem to resolve itself? If so, what would be the time frame for this

    If I left the toe to resolve itself are there potential complications in doing so which I should be aware of?

    If this is a local allergic reaction to the phenol, when would you expect the inflammation to resolve?

    I appreciate any advice on this, having qualified 2 years ago this is the first time I have come across the above problem. It is something which I also never had to deal with when attending university.

    Many thanks

    Alan
     
  2. W J Liggins

    W J Liggins Well-Known Member

    This sounds like one of three things. i) as you suggest, the base has healed over but the deeper tissues are not healed and drainage was not established (you don't mention the post-op. instructions - NaCl footbaths for example) ii) The area is infected. Who took the swab? It is all too easy to be too superficial, and these things matter; the negative result does not mean infection is not present. iii) You penetrated the common integument and the patient is experiencing a sterile bone necrosis. These differential diagnoses are far more likely than the remote possibility of allergic reaction to phenol - the stuff is everywhere, even in carbolic soap.

    My view is that if you decide to do nothing then you are in potential danger of litigation and doing nothing is not a defensible action. At least diagnose the problem by opening the eponychium, establish drainage, take a further swab, instruct the patient to use NaCl footbaths. If this fails to resolve the problem then an Xray of the digit will be necessary and referral on to a podiatric surgeon for treatment as necessary.

    Let us know the outcome.

    Bill Liggins
     
  3. alanpackwood

    alanpackwood Member

    Thank you for the prompt reply.

    I plan to discuss the patient with the GP today and I will mention about the swab as I do not know who did it within the GP practice. I am seeing the patient again in a few days time so I will reopen the site of the surgery and check for signs of leakage, I will also look to take another swab if necessary.

    I will keep you updated on the progress.

    Thanks again for the advice, it has been reassuring and has re-focused me on the best way ahead for the patient.

    Rgds

    Alan
     
  4. alanpackwood

    alanpackwood Member

    Hi Bill,

    I decided to speak with the patient's mother over the phone before talking to the GP to confirm exactly what the GP said. The mother attended the GP appointment with her daughter, whereas the father was the person who attended my clinics with his daughter.

    The mother confirmed the swab had identified a bacterial infection and antibiotics had been prescribed, she put the misunderstanding about the father saying there was no infection down to a communication problem between her and her husband. Unfortunately, being 12 the daughter was not very forthcoming with information when I was talking to the father and her.

    The mother stated the toe is looking 'a lot better' and the swelling and redness have more or less gone. So it looks like it was an infection after all, however, I still plan to see the daughter next week and will continue to do so until I am happy all is well.

    I appreciate your advice, it made me take a step back and refocus on my approach to this patient. I have also learnt a few lessons which I will not forget.

    Many thanks

    Alan
     
  5. W J Liggins

    W J Liggins Well-Known Member

    Thanks Alan

    'They' say that 90% of the world's problems are associated with communication! It would have been nice if the GP had let you know but it is good to hear all is well now.

    All the best

    Bill
     
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