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PNA day 1 - inflammation?

Discussion in 'General Issues and Discussion Forum' started by hard_corn, Dec 12, 2013.

  1. hard_corn

    hard_corn Member

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    Hello, I have recently undertaken a Lateral hallux PNA with matrix phenolisation. At review today (surgery yesterday), the sulci is quite inflamed. At day 1 is this reaction normal?? There was minimal exudate and the patient is without pain.
    I would be grateful of your opinion, many thanks. Image attached.
  2. toughspiders

    toughspiders Active Member

    see note below
  3. toughspiders

    toughspiders Active Member


    Looks a bit too much inflamed for my liking i note also the colour of the remaining nail and the medial edge and also the inflammation around the little piggy that stayed at home... what was it like prior to surgery?
  4. hard_corn

    hard_corn Member

    Thanks toughspiders, yes inflammation was present prior to surgery yesterday. It seems the phenol has really caused an inflammation?. Patient reports slight uncomfortableness but no throbbing pains and nil pain whilst seated. I have told patient to call me if any pain presents in interim, and have commenced saline soaks with dry dressing until review on Monday.. Makes me a bit anxious seeing inflammation like this
  5. Trevor Prior

    Trevor Prior Active Member

    Phenol will cause some inflammation and symptoms and you need to take great care on deciding at day one. Pain is the single biggest indicator of infection in the early stages so, unless overt neuropathy, if there is no pain, infection is less likely. The picture also has to be compared to the pre-operative level of inflammation. I could argue that there is some redness/inflammation extending to the lateral base of the toe and, at a push, early signs to the dorsum of the foot. You mention it was inflammed pre-op but then say seeing this inflammation at one day worries you - is it significantly greater? Applying phenol for up to 3 minutes is likely to cause a reaction - it would if you rubbed it into your hand for this period. Whilst rare, the patient may also react to the phenol with a flare.

    Seeing as I never see my patients at day 1 but have them remove the dressings and start twice daily saline soaks and dry dressing, I would say you have done exactly the right thing.

    On Monday, it will probably still be inflammed but as long as it is not worse and there is no pain, I would continue with the dressing regime.

    I am interested that you did not consider a procedure to the tibial sulcus at the same time - looks pretty uncomfortable.

  6. hard_corn

    hard_corn Member

    Thanks a lot Trevor. Yes it was inflamed pre-surgery, and no it probably isn't that much more inflamed post-surgery. The largest part of inflammation seems to be adjacent to the lateral sulcus. I guess what makes it stand out so much is the wound where the offending nail and spicule was growing into the skin.. Also it was a difficult nail to remove and required a bit of force with the elevator. How long would you expect a wound like this to heal, in your experience Trevor?
    In the absence of any pain on Monday, and no further increase in inflammation, I will continue with dressing regime. If however inflammation continues I will refer to GP.
  7. hard_corn

    hard_corn Member

    Also re: tibial sulcus, didn't do it because wanted to see how the patient would heal from one side first.. I guess I didn't want to compound the wound.. Overly conservative probably
  8. toughspiders

    toughspiders Active Member

    Hi Hard corn,

    Its looks like the remaining nail may become loose, maybe from the force of you trying to remove the awkward edge with an elevator.

    I'm not sure how many nail surgeries you have done. Do you not have any support :( if so that is a shame,

    I don't use an elevator for a PNA I just use a beaver to cut and the forceps to remove.

    I don't review on day 1.

    I would also have done both sides!!! One toe if its slow healing its slow healing on one toe. I wouldn't even worry unless they were high risk and in which case experience is a must.

    If you need any more tips i am happy for ou to PM me

  9. Trevor Prior

    Trevor Prior Active Member

    It would be tough to remove as there was probably quite a bit of fibrosis, a thickened nail and the involution.

    With nails like this, the elevator elevates too much of the nail plate. In these instances, I use the forceps to elevate the nail as I still use thwaites but many just use the beaver as has been indicated.

    I would estimate that this will take 2-4 weeks to heal if they continue with daily saline soaks (my patients do this twice per day for 15 mins). Given your concern just keep an eye on it and I would only refer if it deteriorates or becomes more painful etc. I think you will find it will settle with little trouble but, if they get an infection, it will settle with a week of antibiotics.

    I would have had no hesitation in performing bilateral surgery and agree with the 'toughspiders'. My patients start re-dressing at day 1, they review with the GP practice nurse at 1 week and see me in clinic at 6-8 weeks although get in contact if any concerns. They continu etwice daily soaks until the sulcus is dry. We are in the process of reviewing the audit data on this approach which I have used for as long as I can recall.

  10. hard_corn

    hard_corn Member

    Thanks so much Trevor and toughspiders for your wisdom, very much appreciated. I will update you next week.
  11. Ros Kidd

    Ros Kidd Active Member

    Looking at the lesser piggy and the medial sulci I would probably have done a TNA especially if they were high risk, no incision needed just shell off the nail with an elevator.
  12. Jose Antonio Teatino

    Jose Antonio Teatino Well-Known Member

    My patients, in the same cases, takes five weeks to heal.
    I have no doubt that with a shingle nail clamp so evolved, I prefer the complete removal phenolization.
    Maybe also in 2nd finger ...
  13. sandra.jones

    sandra.jones Member

    I agree with Ros on this. TNA for hallux and second nails; both too curved to be suitable for PNAs

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