Alteration to surrounding tissue

Subungual haemorrhage

Tennis (or sportman's) toe is a brown-black discoloration due to subungual haemorrhage caused by special stresses on the longest toe (great toe and/or the second toe). Pain is associated with the appearance of the damage. In tennis, this occurs because the player frequently stops abruptly; the forward motion of the body propels the toes into the toe box and tip of the footwear. Hard playing surfaces contribute to the injury.

In distinction to tennis toe, jogger's toe tends to involve the third, fourth and fifth toes, apparently due to the constant pounding of the foot on the running surface. The process begins with erythema, oedema and onycholysis or subungual haemorrhage. Throbbing pain often accompanies this condition. Secondary infection resulting in cellulitis and abscess formation may be a rare complication.

Hyperkeratotic changes

Any abnormal intermittent pressure is likely to lead to the development of hyperkeratosis. Typical predisposing factors include:

• abnormal gait or foot mechanics

• poor fitting footwear

Corns and callosity

Callosity (callus) develops as a result of intermittent shear and pressure leading to a characteristic yellow thickening of the stratum corneum. Callus on the digits develops most commonly on the lateral side of the fifth toe in women as a result of tight footwear. Where toes are hammer or clawed in shape, apical callus may also develop, and may extend proximally under the nail plate (Figure 9.24).

Corns (heloma, clavus) are the next stage of callus development. Continued pressure results in a sharply demarcated area of hyperkeratosis with a central core or nucleus which protrudes deep into the dermis, causing pain and local inflammation (Figure 9.25). Subungual corns are most commonly observed in the hallux as a result of pressure from footwear, or from a nail or toe deformity such as involution. Typically, lesions develop in the lateral nail sulci or along the distal nail edge (Figure 9.26). As the lesion develops subungually local onycholysis is seen with a subtle yellow discoloration of the detaching nail plate. At this stage differentiation is required from a subungual exostosis or other

Helomas Apical

Figure 9.24

Apical corn (heloma). These lesions often extend proximally under the nail plate.

Figure 9.24

Apical corn (heloma). These lesions often extend proximally under the nail plate.

Nail Disorders Corn

Figure 9.25

Hyperkeratosis due to footwear and neglect. A large corn can be seen adjacent to the fifth nail. (Courtesy of B.Wing.)

Figure 9.25

Hyperkeratosis due to footwear and neglect. A large corn can be seen adjacent to the fifth nail. (Courtesy of B.Wing.)

Subungual Heloma

Figure 9.26

Subungual corn: (a) nail intact; (b) nail plate clipped away to show the heloma.

Figure 9.26

Subungual corn: (a) nail intact; (b) nail plate clipped away to show the heloma.

Onychophosis

Figure 9.27

Toe X-ray showing a dorsal hyperostosis.

Figure 9.27

Toe X-ray showing a dorsal hyperostosis.

phalanx abnormality such as tufting (Figure 9.27). Pressure on a subungual corn will lead to blanching, whereas an exostosis offers solid resistance and does not blanch. Radiological imaging is required to establish the diagnosis.

Onychophosis

Corns and callus that develop in the lateral nail folds are termed 'onychophosis'. The condition typically arises as a result of pressure from adjacent or overriding toes, tight footwear, or underlying an involuted nail (Figure 9.28). The condition for many is asymptomatic but frequently it may cause considerable pain when any direct pressure is applied to the distal aspect of the nail plate.

Complications of hyperkeratosis

When the forces of pressure become overwhelming, local haemorrhage or extravasation may appear in the hyperkeratotic tissue

Onychophosis Sulci

Figure 9.28

Painful lateral hyperkeratosis (from repeated microtrauma)— onychophosis.

Figure 9.28

Painful lateral hyperkeratosis (from repeated microtrauma)— onychophosis.

Extravasated Callus

Figure 9.29

Extravasated apical callus, following debridement, in a person with diabetes.

Figure 9.29

Extravasated apical callus, following debridement, in a person with diabetes.

giving a red-brown spotted appearance. This is a sign that ulceration is likely to ensue and therefore requires preventive measures (Figure 9.29).

Treatment of hyperkeratotic changes

When hyperkeratotic changes around the nail give rise to symptoms, immediate treatment involves conservative resection of the nail plate to expose the lesion. Hyperkeratosis can then be debrided by a scalpel. Stubborn sulcal callus may benefit from hydrogen peroxide solution applied to it prior to treatment. Where the overlying nail is thickened or deformed, reduction of the nail by drilling may be required and nail edges should be filed well back (Figure 9.30). Following resection, packing the nail sulci lightly with cotton wool may reduce discomfort.

Preventive measures include the regular application of urea-based emollients to the nail sulci to soften the surrounding skin. Footwear should also be assessed and appropriate advice should be given. Where possible overlapping toes or other causative digital

Nail Disorders Nursing

Figure 9.30

An electric nail drill with diamond burr. deformities may be accommodated and protected by the use of silicone appliances.

Figure 9.30

An electric nail drill with diamond burr. deformities may be accommodated and protected by the use of silicone appliances.

Onycholysis and onychomadesis

Excess friction between the nail and the shoe may result in onycholysis and even in fluid-filled blisters. These subungual bullae can sometimes be haemorrhagic (Figure 9.31). Similar friction at the base of the nail may produce onychomadesis. Separation of the nail from the subungual tissue is often seen in ballet dancers who dance on 'points' and in footballers. Subungual hyperkeratosis is usually associated with excessive pressure and related onycholysis, and occasionally onychomycosis, especially in the elderly. Overlapping of the second toe on the lateral aspect of the hallux may also produce onycholysis in this area with or without haemorrhage (Figure 9.32). Careful examination of the toe box of the regular footwear may reveal bulging or tearing of the leather internally when footwear is at fault.

Figure 9.31

Traumatic onycholysis following bulla formation.

Figure 9.31

Traumatic onycholysis following bulla formation.

Fingernail Abnormalities Photos

Figure 9.32

'Primary' onycholysis due to pressure from the second toe.

Figure 9.32

'Primary' onycholysis due to pressure from the second toe.

Onychocryptosis

Onychocryptosis is the term applied when the nail plate embeds, to varying degrees, into the periungual tissues. Four types can be described in adults:

• juvenile ingrowing toe nail

• hypertrophy of the lateral lip

• pincer or involuted nail

• distal nail embedding.

Juvenile ingrowing toe nail (subcutaneous ingrowing nail)

Ingrowing toe nail is created by impingement of the nail plate onto the dermal tissue of the lateral nail fold. This often results from improper trimming of the nail. Consequently, a lacerating spicule of the nail pierces the soft tissue surrounding the side of the nail, acting as a foreign body and producing inflammation with pain from perforation of the nail groove epithelium. Juvenile ingrowing toe nail (Figure 9.33) is most frequently observed in the hallux of

Hypertrophic Granulation Tissue

Figure 9.33

Ingrowing toe nail with chronic granulation tissue formation.

Figure 9.33

Ingrowing toe nail with chronic granulation tissue formation.

adolescents, rarely seen in the lesser digits. The relatively thin nail plate, in combination with hyperhidrosis softening the surrounding skin, promotes the development of the condition. Bilateral cases are common, particularly where there is a family history of ingrowing nails.

Conservative treatment, with or without local anaesthesia, in mild cases consists of resection of the offending nail spike using nail clippers or a scalpel blade. Once the nail fragment has been retrieved, the nail edge should be filed smooth. In some cases cotton wool packing may prevent further trauma from the nail plate on the affected sulci. Any local infection should be treated with the appropriate systemic antibiotics. Subsequently the patient should be advised with regard to proper nail care to prevent recurrence. Unfortunately, as conservative management requires a high degree of compliance, recurrences are frequent. Sometimes, the nail groove becomes involved along its entire length by excess granulation tissue which may extend beneath the nail and overlap its dorsal aspect.

The definitive treatment procedure calls for selective matrix horn removal, under local anaesthesia, which permanently narrows the nail (Figure 9.34). A nail elevator is used to free a lateral nail strip down to the proximal nail fold, nail bed and matrix. Nail nippers are then used to cut the nail vertically along its length to the matrix, under the eponychium. Locking forceps are applied to the separated nail section and medially rotated until the section is freed. The area is then washed with saline and cleared of any debris prior to a 3-minute application of liquefied phenol. This is applied and worked into the exposed nail matrix and nail bed using a Black's file or similar instrument. The area is then carefully dried and dressed. Postoperative pain is minimal since phenol has local anaesthetic action and is also antiseptic. The matrix epithelium is sloughed off and there is usually slight oozing for 2-4

Matrixhorn

Figure 9.34

Nail wedge resection procedure, (a) nail edge is elevated; (b) nail is cut using Thwaite nipper; (c) forceps are attached and the section of nail is

Figure 9.34

Nail wedge resection procedure, (a) nail edge is elevated; (b) nail is cut using Thwaite nipper; (c) forceps are attached and the section of nail is medial rotated; (d) Liquid phenol solution is applied for 3 minutes; (e) end result following resolution.

weeks. Daily footbaths with hypertonic saline minimize the risk of infection and assist healing.

Hypertrophy of the lateral lip

Hypertrophic lateral nail fold usually accompanies long-standing ingrowing toe nail deformities. The nail looks normal or slightly involuted, but a soft tissue lip overgrows around the edge of a nail plate and onychophosis may develop in the affected sulcus (Figure 9.35). The hypertrophic lip usually forms along the fibular sulcus of the hallux as a result of the adjacent second toe impinging upon it, rolling the flesh around the nail plate. Hypertrophic lips on the tibial sulcus of the hallux occur often as a result of abnormal locomotor forces secondary to toe deformities such as hallux valgus and hallux rigidus.

Where toe impingement is a problem, silicone interdigital wedges may reduce symptoms (Figure 9.36). Surgical treatment consists of narrowing the nail by cauterization of the lateral horn of the nail matrix, as for juvenile ingrowing toe nail. Complete removal of the affected part of the nail and the hypertrophic lateral nail fold may be achieved by the Winograd procedure (Figure 9.37). Using a double incisional technique an entire wedge of nail plate, matrix and nail fold is removed down to bone and the remaining edges are brought together with sutures. This procedure is also occasionally used to treat juvenile ingrowing toe nails, when faster healing times are required.

Pincer nail (trumpet nail, omega nail, involuted nail)

Pincer nail is a dystrophy characterized by transverse overcurvature increasing along the longitudinal axis of the nail and reaching its greatest extent at the distal part. The edges constrict the nail bed tissue and dig into the lateral nail grooves. Pain is usually not too severe but may sometimes be excruciating, and onychophosis may be present. On

Onychophosis

Figure 9.35

Hypertrophy of the lateral lip (nail fold).

Figure 9.35

Hypertrophy of the lateral lip (nail fold).

Clavis Intergital Infection

Figure 9.36

Silicone interdigital wedge, preventing pressure of the fibular sulcus of the hallux.

Figure 9.36

Silicone interdigital wedge, preventing pressure of the fibular sulcus of the hallux.

Lateral Nail Fold
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Responses

  • vigo
    How to stop the pain from a pounding blister around nail of second biggest toe?
    6 years ago
  • Mikolaj
    How to soften the skin from onychophosis?
    4 years ago

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