Hands On Nail Surgery W002

Transcription

1 DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY Hands On Nail Surgery W002 Molly Hinshaw, MD Associate Professor of Dermatology & Dermatopathology UWHealth in Madison, WI DISCLOSURES I do not have any relevant relationships with industry.

2 PHOTOGRAPHY & VIDEOTAPING ARE STRICTLY PROHIBITED IN ALL EDUCATIONAL SESSIONS CELL PHONES MUST BE PLACED ON VIBRATE OR TURNED OFF Violations of this policy will result in removal from the session and possible revocation of meeting registration. Session directors will be closely monitoring such occurrences. FOTOGRAFIA E FILMANDO SÃO ESTRITAMENTE PROIBIDOS EM TODAS AS SESSÕES EDUCACIONAIS TELEFONES CELULARES DEVEM SER COLOCADOS EM VIBRAR OU DESLIGADOS Violações desta política resultará na remoção de sessão e possível revogação do registo da reunião. Diretores de sessão irão acompanhar de perto tais ocorrências.

3 Using Knowledge of Nail Anatomy Choose a Surgical Approach to Address Source of Pathology Indications for Nail Surgery Melanonychia-with unusual features Onychodystrophy-single nail Onychodystrophy-multiple nails, rapidly evolving Subungual pain Erythronychia-single nail Surgical Approaches Tangential shave biopsy/excision Lateral longitudinal excision Excision: matrix, bed Punch biopsy: matrix, bed Flap Nail unit excision (Mohs)

4 Nail Unit Anatomy

5 Course Agenda

6 Introduction to Nail Surgery Pre-operative education Intra-Op: Anesthesia Intra-Op: Asepsis Intra-Op: Avulsions

7 Pre-Op: Pt Education Pays dividends in time, complications Explain entire surgery and post-op course Discuss risks, benefits Allow time to answer all questions Risks of stopping anticoag outweigh benefits Raynauds-no Epi Verbal & written post-op care instructions before surgery

8

9 Pre-Op: Pt Education Reassure them that you will control their pain Pain minimization strategies (Dr. Adigun) Offer appointment for first dressing change Discuss activity restrictions

10 Intra-Operative: Surgical Tray

11 Intraop: Useful Surgical Tray

12 Intraoperative: Anesthesia

13 Anesthesia Anesthetic Onset Duration without Epinepherine Lidocaine <1 min min Vasodilating Bupivacaine 2-5 min min Longer duration Ropivacaine 1-15 min min Vasoconstricting, less cardiotoxic than bupivicaine Digital blocks (proximal vs distal) Some evidence that the subcutaneous variation of palmar block (3mL into subq not tendon sheath) has less post-op pain than transthecal, less theoretical risk tendon inflammation/infection/trigger finger Jellinek NJ, Velez NF. Nail Surgery: Best Way to Obtain Effective Anesthesia. Derm Clinics 2015;33:

14 Comparison Proximal Block During Laceration Repair: Single sq Volar vs Two Lateral Randomized, prospective, 50 pts>18y/o (78% male) in ED with finger laceration any digit, n=63, 1 investigator, used lido 2% w/epi mg/mL Single sq volar: 3mL inject vertically through distal joint line of volar MCP Dual Dorsal: 1.5mL on each side, enter dorsally, inject half, push needle thru & inject rest volar Outcomes: 1. pain during anesthesia, 2. pain during suturing 3. onset time of total anesthesia, 4. need for additional aesthesia Visual analog scale (VAS) used for pain score Conclusions: No statistical difference in any of 4 measures. Single injection volar nerve block technique is suitable for digital anesthesia in emergency departments Okur, OM. Two injection digital block vs single subcutaneous palmar injection block for finger lacerations. Eur J Trauma Emerg Surg 2016; DOI /s

15 Comparison of Proximal Blocks: Single sq Volar vs Two Lateral Randomized, prospective 86 pts>18y/o in ED with finger injury (laceration (n=63), dislocation, crush, fracture, infection, other), multiple surgeons, lidocaine 1% without epi Also did not limit to digits 2, 3, 4 Single volar (n=41) performed via sq (not transthecal) route, 2-3mL Double dorsal (n=27)=1ml each side of proximal phalanx just distal to MCP 1 outcome=pain score during injection; 2 =pain of injury 5 min after anesthesia, success of anesthesia defined as ability to proceed without additional anesthesia, complications Conclusion: No statistical difference in single volar and double dorsal proximal block injection pain or anesthesia effectiveness Martin SP. Double-dorsal vs. single-volar digital subcutaneous anesthetic injection for finger injuries in the emergency department: A randomized controlled trial. Emerg Med Austral 2016;28:193-8.

16 Block Onset Anesthetic Quantity Uses Proximal sq digital block Distal digital block aka wing block Up to 10 min 1-2% Lidocaine without epi or ropivacaine Few minutes 1-2% lidocaine with or without epi or use ropivacaine Matrical Few minutes Same as distal digital 2-3mL 0.5-1mL each side Same as distal digital Any digit Many inc. for epi or volumetric hemostasis; use quantity if working on PNF Midline lesions that do not need avulsion

17 Intra-Operative: Asepsis

18 Surgery: Minimizing Infection Risk Surgical scrub Sterile drape, consider applying a glove to patient s hand Control bleeding with pressure, tumescence Daily dressing changes, gentle soap and water Limit activity, trauma

19 Asepsis Pre-operative scrub with alcohol alone or with + chlorhex or iodophore alone OR chlorhexidine OR iodophor Rutala WA, Weber DJ. Disinfection, sterilization, & antisepsis: An overview. Amer J Infect Control 2016;44:1-6e

20 General Principals of Nail Surgery: Hemostasis Do not stop anticoagulants Generally do not need chemical nor cautery Use pressure Use volumetric anesthesia OK to use aluminum chloride Cautery carries significant risk of scar

21 Pre-& Intra-Op Issues for All Nail Surgeries Pre-Op: Pt education (critically important) Intra-Op: Asepsis (alcohol then chlorhexidine) Intra-Op: Anesthesia (consider ropivacaine) Intra-Op: Suture choice (consider polyglactin 910)

22 Avulsions Partial avulsions Do not force avulsion Replace plate whenever possible Abimelec P, Dumontier C. Basic and Advanced Nail Surgery. In: Nails Dx, Rx, and Surgery Scher RS & DanielsCR Eds. Elsevier 2007.

23 Thank You! Molly Hinshaw, MD Associate Professor of Dermatology & Dermatopathology UWHealth in Madison, WI

24 Blocks & Avulsions: Hands On Time Partial avulsions when possible Do not force avulsion Replace plate whenever possible Abimelec P, Dumontier C. Basic and Advanced Nail Surgery. In: Nails Dx, Rx, and Surgery Scher RS & DanielsCR Eds. Elsevier 2007.