E.J. Mayeaux, Jr., M.D., FAAFP
Associate Professor of Family Medicine
Clinical Associate Professor of Obstetrics and Gynecology
Louisiana State University Medical Center
Shreveport, LA

In humans, fingernails and toenails perform the physiologic functions of protecting the distal phalanges, increasing mechanical traction, and enhancing fine touch. We also use them for social functions such as scratching, grooming, and aesthetic adornments. Nail deformities may result from a number of etiologies, and surgical modalities may be needed to diagnose and treat a number of abnormalities.

The hard, flexible nail plate is composed of keratinized squamous cells and is commonly referred to as the nail by the general public. It is bordered by proximal and lateral nail folds and contains parallel longitudinal grooves on its dorsal surface. The highly vascular nail bed is the softer tissue that provides germinal tissue for the overlying nail plate. It contains longitudinal ridges that interdigitate with those on the nail plate, securely attaching the two structures. It is bordered proximally by the lunula, laterally by the lateral nail folds, and distally by the hyponychium.

The hyponychium lies between the distal portion of the nail bed and the distal groove. It underlies the distal portion of the attached nail plate and marks the transition to normal volar epidermis. The part of the hyponychium that reflects onto the undersurface of the distal nail plate is called the solehorn (or onychodermal band), which serves as a waterproof barrier sealing off the potential space below the nail plate. The distal nail fold is the indention just below the free edge of the nail plate.

The nail matrix is the germinal center of the nail complex. The proximal matrix produces the dorsal part of the nail plate, and the distal portion (with some contribution of the nail bed) produces the ventral surface. The proximal nail fold covers most of the matrix, with the part visible under the proximal nail plate being called the lunula. Melanocytes are most prevalent in the distal matrix and are absent in the nail bed. Fingernail plates grow on average at a rate of 3mm per month (6 months to fully regenerate a nail), and toenail plates grow at half to one third that rate.

The ventral part of the proximal nail fold is called the eponychium. The cuticle is situated between the nail proximal fold and the nail plate where it is closely adhered to the dorsal surface. It seals off the potential space between the proximal nail fold and the nail plate. The anterior ligament attaches the distal phalanx to the hyponychium, and the posterior ligament attaches the matrix and proximal nail fold to the proximal part or the distal phalanx.

The digital ring block is commonly used for anesthesia for a variety of nail procedures. Lidocaine without epinephrine is used in the digits, and a fine gauge needle and slow rate of injection may minimize pain. Using a 30-gauge needle, slowly raise a weal at the base of the toe on the dorsal surface of one side of the digit. Without removing the needle, direct it toward the plantar surface, delivering approximately 1ml of anesthetic to the extensor and plantar branches of the digital nerve. Perform a second puncture at the corresponding site on the other side and advance the needle in the plantar direction to allow delivery of 1 ml of anesthetic to each branch of the digital nerve. Anesthesia is achieved in 5 to 10 minutes.

An ingrown toenail (Onychocryptosis) is a common affliction that can result from a variety of conditions that result in improper fit of the nail plate in the lateral nail grove. Patients often seek treatment because of the significant levels of discomfort and disability associated with the condition. The medial or lateral border of the great toe is usually the only nail involved.

Palliative measures to relieve painful symptoms of ingrown toenail include elevation of the involved nail edge with a cotton wick, selective trimming of the affected nail edge, frequent soaking, oral or topical antibiotics, and the use of loose-fitting footwear. ¹ Unfortunately, resolution of ingrown toenail is rare without an operative approach. Partial removal of the toenail remains the definitive treatment for bothersome ingrown nails. For patients without peripheral vascular disease, diabetes, or collagen vascular disease, ablation of the lateral germinal nail tissue can be used to lower the recurrence rate. ¹

• Onychocryptosis (ingrown nail)
• Onychomycosis (fungal infection of the nail)
• Chronic, recurrent paronychia (inflammation of the nail fold)
• Onychogryposis (deformed, curved nail)

• Allergy to local anesthetics
• Bleeding diathesis

• 3 ml or 5 ml syringe with long (1 or 1.5 inch) 25- or 27-gauge needle
• Local anesthetic without epinephrine.
• A narrow periosteal elevator (nail elevator)
• Sterile scissors with straight blades or nail splitter
• Rubber band or small Penrose drain
• Two straight hemostats
• Alcohol swabs
• Sterile gauze and tubular gauze dressing
• Topical antibiotic ointment
• If desired, phenol solution (88%) or a radiofrequency electrosurgical unit with a Teflon-insulated matrix tip

Technique - Partial or Full Nail Removal

• With the patient in a relaxed, supine position, scrub and drape the toe in a sterile fashion.
• Administer local anesthetic (5 ml total) in ring-block as described above.
• When anesthesia is achieved (5 to 10 minutes), use a straight hemostat to firmly secure a wide rubber band around the base of the toe to serve as a tourniquet.

• Loosen and lift the nail from the nail bed by using the flat, pointed blade of a pair of scissors, a single jaw of a straight hemostat, or a narrow periosteal elevator. Introduce and advance the instrument with continued upward pressure against the nail and away from the nail bed to minimize injury and bleeding. It is important to completely free the proximal nail at its base under the edge of the cuticle to allow removal and to expose the germinal tissue of the nail bed. Separate at least 25% of the nail for a partial nail removal or loosen the entire nail for a complete nail removal.

• For a partial nail removal, use scissors or a nail splitter to completely split the nail in a longitudinal direction to include the base of the nail that rests beneath the cuticle.

• Grasp that portion of the nail to be removed lengthwise with a straight hemostat and remove it, using a steady pulling motion with a simultaneous upward twist of the hand toward the affected side. This twisting action will ensure that the nail will be rolled out from beneath the affected nail margin instead of rolling over it. If the entire nail is to be removed, the nail may be removed in two halves or in its entirety, following a thorough loosening and lifting of the nail. In removing the entire nail, the forceps should produce lifting and distal traction on the nail as it separates from the nail bed.

• Remove total or partial nail as described above.
• Sponge the exposed nail bed dry with cotton balls or swabs.
• Cauterize the germinal tissue, including that under the cuticle, by application of phenol on a cotton swab to the nail bed tissues. Use caution to avoid phenol contact with normal skin. Hold the phenol-dampened cotton swab in place for 3 minutes. With partial nail removal, the goal is to ablate only the lateral edge of the nail matrix where the overgrowth is a problem. Then swab the area with isopropyl alcohol to neutralize the phenol.
  
  Alternatively, a radiofrequency electrosurgical unit can be used to ablate the matrix, which may decrease the inflammatory response. ¹ Place antenna or grounding electrode lead under the heel of foot. Turn unit to "Hemo-part rect" or "coagulation" setting and set the power to a low level. Insert an insulated matrixectomy tip over the nail matrix (extending under the proximal nail fold), insulated side up. The partially insulated probe prevents damage to the undersurface of the proximal nail fold while ablating the nail matrix. A slight upward pressure should be exerted against the undersurface of the nail fold to produce a slight gap between electrode and matrix. Apply power and slowly withdraw the electrode in 5 to 10 seconds. This step can be repeated once after a 15-second cooling period. Multiple applications are necessary if ablation of the entire nail plate is desired. A 3 - 5mm ball electrode or small skin loop may be used to destroy or remove hypertrophied lateral fold granulation tissue.

Apply antibiotic ointment to the nail bed, cover with a sterile gauze pressure dressing, remove the tourniquet, and wrap with tubular gauze dressing. The foot should be rested and preferably elevated during the first 12 to 24 hours. Because phenol ablates the nerve endings of the nail plate, pain should be absent when it is used. There is minimal pain with the radiofrequency unit. Nonsteroidal antiinflammatory drugs (NSAIDs) may be used for discomfort.

The dressing should be changed every 24 hours, at which point normal ambulation may fully resume. The toe should be soaked and cleaned in warm water and topical antibiotics are recommended until healing is complete. Tell the patient to expect a sterile exudate from the nail bed for several weeks. Emphasize proper nail hygiene to prevent further recurrences.

• Infections (Treat with soaks and appropriate antibiotics.)
• Regrowth of nail and return of symptoms (Regrowth rate following phenol cauterization is 4% to 25%; for radiofrequency, less than 5%.)

CPT / BILLING CODES ²

11730* Avulsion of the nail plate, partial or complete, simple; single.

11732 Each additional plate (list separately in addition to 11730)

There are numerous benign causes of pigmented nail plate streaks including trauma and malnutrition, and they may be a normal occurrence in many of African or Asian descent. However, since melanocytes are present in the nail matrix, malignant melanomas may develop under the nail plate. Primary subungual malignant melanomas account for up to 3.5% of all cutaneous malignant melanomas (15% to 20% in blacks). Distinction between benign lesions and malignant lesions is frequently difficult, and biopsy is often recommended to confirm the diagnosis. ³

• Longitudinal pigmented linear streak in the nail plate suspicious for malignancy
• Diagnosis of tumors
• Thickened, distorted nail plate with a negative evaluation for fungal infection (potassium hydroxide (KOH) scraping, culture)

• Longitudinal melanonychia accompanied by periungual pigmentation (Hutchinson's sign). This carries a high risk of subungual melanoma and radical excision may be indicated. ⁴
• Allergy or sensitivity to local anesthetics
• Bleeding diathesis

• 3mm disposable punch biopsy
• Local anesthetic without epinephrine
• Sterile scissors with straight blades (or nail splitter)
• Narrow periosteal elevator (or Freer septum elevator)
• Sterile rubber band or small Penrose drain for use as a tourniquet
• Two sterile straight hemostats
• Sterile gauze and tubular gauze dressing
• Topical antibiotic ointment
• 5 - 0 or 6 - 0 nylon sutures
• Needle holders
• Suture scissors

1. With steady pressure, hold the punch perpendicular to the nail. Rotation of the punch will painlessly produce a round biopsy specimen. No anesthetic is required.
2. Elevate the biopsy sample and separate the underlying nail bed tissue with the scissors or scalpel.

Nail Bed Biopsy Technique


1. Employ anesthetic using the digital ring block technique.

2. Partially remove the nail plate as described in Treatment of Ingrown Toenails. The removal may be partial or complete, depending on the size and location of the area to be biopsied.
3. If necessary, incisions may be made at the junction of the proximal and lateral nail folds. The proximal nail ford can then be retracted with a hook for better exposure of the matrix. ³
4. When the affected nail bed has been exposed, select a 2 or 3 mm punch trephine. Place the end over the most proximal area to be biopsied and twist in a back-and-forth motion. Be careful not to completely bisect the matrix since this will result in permanent split-nail deformity, and avoid the matrix if the same information may be obtained elsewhere. ³ Avoid doing a biopsy in the lunula if possible.

5. Using either a needle placed into the biopsy sample or a pair of smooth pick-ups, place gentle upward traction on the sample and sharply dissect it from the underlying subcutaneous tissue. Place in formalin for pathological examination.

6. Close the biopsy site with one or two 5 - 0 or 6 - 0 nylon sutures oriented along the longitudinal plate. With careful placement, sutures are unnecessary for the incised nail folds. Always use sutures on the matrix.
7. Apply a dressing of antibiotic ointment and sterile gauze.

• Bleeding
• Infection

CPT / BILLING CODE ²

11755 - Biopsy of nail unit, any method

Subungual hematoma is a common response to injuries of the nail bed and fingertip which result from a direct blow to the fingernail, causing bleeding into the space between the nail bed and the fingernail itself. Intense pain usually results from the pressure generated by the hematoma. Evacuation of the hematoma can produce significant relief and can be safely performed in the outpatient setting. Consider distal digit X-rays with large hematomas.

• Visible, painful hematoma beneath the involved nail

• Crushed or fractured nail
• Hematomas involving greater than 50% of the nail may indicate laceration of the underlying nail bed (Removal of the nail and repair of the laceration is recommended by some experts to avoid a posttraumatic nail deformity. Others recommend leaving the nail in place as a splint. The patient should be warned that the nail may be deformed unless the nail bed is examined and treated.)

• Heat source (alcohol lamp, Bunsen burner), metal paper clip, and forceps or hemostat
• Or battery-operated cautery unit
• Or radiofrequency or electrocautery unit with needle or pointed electrode

1. Wash the digit as thoroughly as possible with an antibacterial soap.
2. Create a hole in the nail directly over the hematoma to allow decompression.

• Paper-clip method. Partially straighten a metal paper clip, grasp it with the forceps, and heat it over the lamp. Place the heated clip firmly on the nail directly over the center of the hematoma. Allow it to melt the tissue for a few seconds until the nail is completely perforated.
• Cautery method. In similar fashion, activate the cautery and apply the tip to the nail to create a hole in the nail bed.

1. In both of these procedures, the heated tip will be cooled by the hematoma upon perforation of the nail, thereby preventing injury to the nail bed. The hole created in the nail should be 1 to 2 mm in size so as not to self-close within a few hours. Elevation of the finger, cool compresses, and a simple bandage are recommended during the first 12 hours.

• infection of the residual hematoma

CPT / BILLING CODE ²

11740 Evacuation of subungual hematoma

Paronychia is acute inflammation of the lateral and/or proximal nail folds that is usually caused by infection. It produces all of the typical signs of local infection, including redness, pain, and swelling. The most common causes are gram positive cocci including Streptococcus pyogenes and penicillin-resistant Staphylococcus aureus. Rarely, Candida may cause mild chronic paronychia. Milder cases may be treated with warm soaks and systemic antibiotics. More severe or recalcitrant cases require incision and drainage. Trauma may predispose to this condition.

• Visible, painful paronychia

• Allergy to local anesthetics (may anesthetize the area with a refrigerant)

• 3 ml or 5 ml syringe with long (1 or 1.5 inch) 25- or 27-gauge needle
• Local anesthetic without epinephrine
• Sterile scalpel with a 11 blade
• Two straight hemostats
• Packing material (if desired)
• Large Bandaid
• Topical antibiotic ointment (if desired)

1. Wash the digit as thoroughly as possible with an antibacterial soap
2. Administer local anesthetic (5 ml total) in ring-block as described above
3. When anesthesia is achieved (5 to 10 minutes), insert an 11 blade into the most translucent part of the lesion on the proximal nail fold. Use a quick, short stabbing motion.
   Alternatively, insert the blade between the nail and eponychium parallel to the nail plate and gently sweep the blade to elevate the eponychium (see figure). A wick may be applied to facilitate drainage. ⁵

4. Consider sending bacterial cultures
5. Packing may be used if the deficit caused by the abscess is significant
6. Have the patient soak the finger for 20 minutes 3 times a day. A large bandaid is the prefered dressing.

• Bleeding

CPT / BILLING CODE ²

10060* - I&D of abscess (inc. paronychia)

10061 - complicated or mutiple