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Dumontier C, Braga da Silva J. Nail dystrophy for the surgeon. HAND SURGERY & REHABILITATION 2024; 43S:101635. [PMID: 38367768 DOI: 10.1016/j.hansur.2024.101635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 12/23/2023] [Accepted: 12/24/2023] [Indexed: 02/19/2024]
Abstract
Injuries to the fingertips are the most frequently occurring damage to the hand. The nail is an exceptional structure within the human body that offers both stability and protection, as well as the ability to perform fine and precise movements. Nail dystrophies are numerous, post-traumatic, post-infection or even degenerative. They raise many difficulties for the treating hand surgeon. Which anatomical structure is dystrophic? Is there any secondary fungal superinfection to be treated before surgery? Among the various techniques proposed, which one will help to improve my patient as a complete cure is rarer than partial failures. In this chapter we have chosen to describe the surgical techniques, their difficulties and drawbacks, that are available for the most frequent dystrophies that the hand surgeons may treat.
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Affiliation(s)
- Christian Dumontier
- Centre de la Main, Clinique les EAux Claires, ZAC moudong Sud, 97122 Baie-Mahault, Guadeloupe.
| | - Jefferson Braga da Silva
- Service of Hand and Reconstructive Microsurgery, Hospital São Lucas, Av. Ipiranga, 6690/Centro Clínico PUCRS, Suite 216, RS 90610-000, Porto Alegre, RS, Brazil; Hospital Moinhos de Vento, Av. Ramiro Barcelos 910, Porto Alegre, RS, 90035-000, Brazil
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Barger J, Hoyer RW. Fingertip Infections. Orthop Clin North Am 2024; 55:265-272. [PMID: 38403372 DOI: 10.1016/j.ocl.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
The fingertip is the interface between humans and the world, including the various thorns, dirty needles, and other hazards to be found there. It is unsurprising that this is the site where hand infections most frequently occur. Although commonly encountered by hand surgeons and other physicians, fingertip infections have several mimics, and diagnosis and management is not always straightforward. Early diagnosis and treatment are key to success. As with all infections, they are more common and are more aggressive in immunosuppressed patients. This article reviews fingertip anatomy, common and uncommon fingertip infections and their mimics, and recommendations for management.
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Affiliation(s)
- James Barger
- Indiana Hand to Shoulder Center, Indianapolis, IN, USA
| | - Reed W Hoyer
- Indiana Hand to Shoulder Center, Indianapolis, IN, USA.
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Bansal A, Relhan V. Acute and chronic paronychia revisited: A narrative review. J Cutan Aesthet Surg 2022; 15:1-16. [PMID: 35655642 PMCID: PMC9153310 DOI: 10.4103/jcas.jcas_30_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Paronychia refers to the inflammation of the tissue which immediately surrounds the nail and it can be acute (<6 weeks duration) or chronic (>6 weeks duration). Disruption of the protective barrier between the nail plate and the adjacent nail fold preceded by infectious or noninfectious etiologies results in the development of paronychia. A combination of general protective measures, and medical and/or surgical interventions are required for management. This review explores the pathogenesis, clinical features, differential diagnosis, medical, and surgical management of paronychia. For the purpose of this review, we searched the PubMed, Cochrane, and Scopus databases using the following keywords, titles, and medical subject headings (MeSH): acute paronychia, chronic paronychia, and paronychial surgeries. Relevant review articles, original articles, and case reports/series published till February 2020 were included in this study.
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Abstract
The fingertip is the most common site of infections in the hand, which frequently are encountered by surgeons, dermatologists, and emergency and primary providers. Their mismanagement may have serious consequences. This review discusses the unique anatomy of the volar fingertip pulp and perionychium and reviews pathophysiology and treatment of acute and chronic paronychia, including the decision for surgical versus medical management, choice of antibiotics, incisional techniques, and postincisional care. Felons and the evidence regarding their management are reviewed. Several infectious, rheumatologic, and oncologic conditions that may mimic common fingertip infections and about which the managing provider must be aware are presented.
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Affiliation(s)
- James Barger
- Division of Hand Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital, MGH Orthopaedic Hand Surgery, Yawkey Center for Outpatient Care, 55 Fruit Street, Suite 2C, Boston, MA 02114-2696, USA
| | - Rohit Garg
- Division of Hand Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital, MGH Orthopaedic Hand Surgery, Yawkey Center for Outpatient Care, 55 Fruit Street, Suite 2C, Boston, MA 02114-2696, USA
| | - Frederick Wang
- Division of Hand Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital, MGH Orthopaedic Hand Surgery, Yawkey Center for Outpatient Care, 55 Fruit Street, Suite 2C, Boston, MA 02114-2696, USA
| | - Neal Chen
- Division of Hand Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital, MGH Orthopaedic Hand Surgery, Yawkey Center for Outpatient Care, 55 Fruit Street, Suite 2C, Boston, MA 02114-2696, USA.
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Ferreira Vieira d'Almeida L, Papaiordanou F, Araújo Machado E, Loda G, Baran R, Nakamura R. Chronic paronychia treatment: Square flap technique. J Am Acad Dermatol 2016; 75:398-403. [DOI: 10.1016/j.jaad.2016.02.1154] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 01/26/2016] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
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Abstract
Chronic paronychia is an inflammatory disorder of the nail folds of a toe or finger presenting as redness, tenderness, and swelling. It is recalcitrant dermatoses seen commonly in housewives and housemaids. It is a multifactorial inflammatory reaction of the proximal nail fold to irritants and allergens. Repeated bouts of inflammation lead to fibrosis of proximal nail fold with poor generation of cuticle, which in turn exposes the nail further to irritants and allergens. Thus, general preventive measures form cornerstone of the therapy. Though previously anti-fungals were the mainstay of therapy, topical steroid creams have been found to be more effective in the treatment of chronic paronychia. In recalcitrant cases, surgical treatment may be resorted to, which includes en bloc excision of the proximal nail fold or an eponychial marsupialization, with or without nail plate removal. Newer therapies and surgical modalities are being employed in the management of chronic paronychia. In this overview, we review recent epidemiological studies, present current thinking on the pathophysiology leading to chronic paronychia, discuss the challenges chronic paronychia presents, and recommend a commonsense approach to management.
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Affiliation(s)
- Vineet Relhan
- Department of Dermatology, VMMC and Safdurjung Hospital, Delhi, India
| | - Khushbu Goel
- Department of Dermatology, VMMC and Safdurjung Hospital, Delhi, India
| | - Shikha Bansal
- Specialist, VMMC and Safdurjung Hospital, Delhi, India
| | - Vijay Kumar Garg
- Director Professor and Head, MAMC, VMMC and Safdurjung Hospital, Delhi, India
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Abstract
Acute and chronic infections and inflammation adjacent to the fingernail, or paronychia, are common. Paronychia typically develops following a breakdown in the barrier between the nail plate and the adjacent nail fold and is often caused by bacterial or fungal pathogens; however, noninfectious etiologies, such as chemical irritants, excessive moisture, systemic conditions, and medications, can cause nail changes. Abscesses associated with acute infections may spontaneously decompress or may require drainage and local wound care along with a short course of appropriate antibiotics. Chronic infections have a multifactorial etiology and can lead to nail changes, including thickening, ridging, and discoloration. Large, prospective studies are needed to identify the best treatment regimen for acute and chronic paronychia.
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Wegener EE, Johnson WR. Identification of common nail and skin disorders. J Hand Ther 2010; 23:187-97; quiz 198. [PMID: 20304604 DOI: 10.1016/j.jht.2009.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2009] [Revised: 12/05/2009] [Accepted: 12/09/2009] [Indexed: 02/03/2023]
Abstract
UNLABELLED NARRATIVE REVIEW: The following review discusses the more common disorders of the perionychium and skin likely to be observed by the hand therapist. To assist the therapist in recognition of abnormalities, the anatomy, physiology, and basic function of the normal nail unit are described. Indications of when disorders of the nail, resulting from trauma, infections, and neoplasms, require referral to another practitioner are discussed. Characteristics of abnormal skin conditions are described with an emphasis on differentiating benign from malignant lesions. By knowing the suspicious characteristics of nail and skin disorders, the upper extremity therapist can positively impact the well-being of his or her patients through quick referral, leading to early diagnosis and treatment of potentially serious disease. LEVEL OF EVIDENCE 5.
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Affiliation(s)
- Eric E Wegener
- Plastic & Hand Surgery Associates, PLLC, Flowood, Mississippi 39232, USA.
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10
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Abstract
Hand infections are very common and must be properly diagnosed and treated to minimize the potentially devastating functional complications. Acute hand infections include felon, paronychia, deep-space infections, septic arthritis, osteomyelitis, and necrotizing fasciitis. Chronic infections are usually caused by atypical mycobacteria and fungi. There are several conditions that mimic acute hand infections, and it is important to recognize them so that the appropriate treatment can be instilled. To prevent all these complications and poor outcome, prompt diagnosis and early institution of appropriate surgical management and antibiotic treatment are crucial.
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Affiliation(s)
- Yee Siang Ong
- Durham, N.C. From the Division of Plastic, Reconstructive, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Medical Center
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Grover C, Bansal S, Nanda S, Reddy BSN, Kumar V. En Bloc Excision of Proximal Nail Fold for Treatment of Chronic Paronychia. Dermatol Surg 2006; 32:393-8; discussion 398-9. [PMID: 16640685 DOI: 10.1111/j.1524-4725.2006.32079.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic paronychia is a very recalcitrant dermatosis, which is particularly prevalent in housewives. Medical treatment for this condition is unsatisfactory in a significant number of cases. Surgical approach forms an important part of management, however, this area has received little attention. Various surgical approaches have been tried in the past but a comparative analysis has not been attempted. OBJECTIVES The present study aims at assessing the efficacy of en bloc excision of proximal nail fold (PNF). Moreover, a comparative analysis has been undertaken to assess whether or not simultaneous nail plate avulsion improves the treatment outcome. METHODS Thirty patients of chronic paronychia with nail plate irregularities were randomly divided into two treatment groups (15 patients each). After a detailed evaluation, en bloc excision of PNF with or without nail plate removal was performed. Postoperative measures were advised and the patients were kept under regular follow-up thereafter. Assessment of postoperative complications was also performed. RESULTS Twelve patients in group I and 13 patients in group II completed the treatment protocol. Of these, 70% of patients were cured in group II (en bloc excision with nail avulsion) whereas only 41% were cured in group I (en bloc excision without nail avulsion). CONCLUSION En bloc excision of the PNF is a useful method in recalcitrant chronic paronychia. Simultaneous avulsion of the nail plate improves the surgical outcome. Strict avoidance of irritant exposure is necessary to ensure complete treatment and prevent recurrence.
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Affiliation(s)
- Chander Grover
- Department of Dermatology, Venereology and Leprology, Maulana Azad, Medical College, New Delhi, India.
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En Bloc Excision of Proximal Nail Fold for Treatment of Chronic Paronychia. Dermatol Surg 2006. [DOI: 10.1097/00042728-200603000-00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
BACKGROUND An untreated hand infection can lead rapidly to tissue destruction and permanent disability. METHODS Review of the pertinent English literature. RESULTS Early diagnosis and timely, effective intervention is crucial to treatment. Anatomically, the hand consists of multiple potential spaces and tissue planes that can become infected with a wide variety of organisms. Thus, a working knowledge of hand anatomy as well as pharmalogical therapies is imperative for successful management. CONCLUSIONS Knowledge of the basic principles of hand care, relevant anatomy, infectious organisms, and clinical signs of an unusually aggressive infection greatly improves treatment efficacy.
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Affiliation(s)
- Marvin Spann
- Department of Surgery, Division of Plastic Surgery, NewYork-Presbyterian Hospital-Weill Cornell Medical College, New York, New York, USA
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Abstract
There are two types of fungi (yeasts and molds) both of which can cause superficial infections of the perionychium. Yeasts (such as Candida albicans) grow as single cells and reproduce by asexual budding. In contrast, molds grow in long filaments, called hyphae. There are approximately 100,000 species of fungi that have been characterized. Most of these are ubiquitous. Fortunately only about 200 are human pathogens, and only a handful are commonly found to be associated with human disease. This article discusses causes, symptoms, diagnosis, and treatment of the most common fungal infections of the perionychium, including superficial dermatophytosis, onychomycosis, and chronic paronychia.
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Affiliation(s)
- York J Yates
- University of Missouri, Division of Plastic Surgery, M349, One Hospital Drive, Columbia, MO 65212, USA
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Abstract
The fingernail and toenail are unique to primates. The anatomy and physiology of the nail must be understood for nail care to be effective. The most common cause of deformity of the nail bed is trauma, which requires careful suturing and postoperative care if the desired results are to be achieved. Congenital anomalies, tumors, and infection can also cause nail deformities and can frequently be corrected or improved surgically.
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Affiliation(s)
- E G Zook
- Institute for Plastic and Reconstructive Surgery, Southern Illinois University School of Medicine, Springfield 62794-9653, USA
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Abstract
A long-term retrospective study of patients with chronic paronychia treated by eponychial marsupialization with or without nail removal is presented. Twenty-eight consecutive fingers with chronic paronychia in twenty-five patients were surgically treated. Symptoms had been present for 28 +/- 7 weeks. Twenty-three of these had nail irregularities. Of this group, the first seven fingers were treated with marsupialization alone. Recurrences developed in two of these. The next sixteen patients with nail irregularities were treated with marsupialization plus nail removal, and there were no recurrences (p less than 0.05). Furthermore, when the two recurrent paronychia were treated with both procedures, one healed completely and the other was markedly improved. All fingers without nail irregularities healed with marsupialization alone. These results confirm that eponychial marsupialization is an effective means of treating chronic paronychia and suggest that nail removal should be done when concurrent nail irregularities are seen.
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Affiliation(s)
- M S Bednar
- Department of Orthopaedics, Hospital for Special Surgery, N.Y., N.Y
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Baran R, Bureau H. Surgical treatment of recalcitrant chronic paronychias of the fingers. THE JOURNAL OF DERMATOLOGIC SURGERY AND ONCOLOGY 1981; 7:106-7. [PMID: 7217504 DOI: 10.1111/j.1524-4725.1981.tb00609.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Abstract
In some investigations Kligman has been thought to have shown that the cul-de-sac in which the nail is formed determines that it should grow outward instead of upward. However, results obtained during the course of nail surgery for chronic paronychia and electron microscopic studies, along with genetic evidence, fail to confirm his observation on the effect of the proximal nail fold on nail growth direction. The whole subject of direction of nail growth remains questionable and worthy of further consideration.
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