OSCE: Removal of Nail or Nail Fold Aka. Nail extraction

📎 Nail extraction.pdf

Patient Introduction and Consent

Indications

• Subungual hematoma.
• Partially or totally avulsed nail.
• Fungal infection (Onychomycosis).

Contraindications

• Absolute:
  • Bleeding diathesis.
• Relative:
  • Allergy to local anesthetic.

Complications

• Bleeding.
• Infection.
• Nail bed injury.
• Paronychial injury.

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Procedure Steps

Equipment Preparation

Required Equipment:

• Antiseptic solution and cotton swabs.
• Sterile drapes.
• 5-10 mL syringe with a fine-gauge needle.
• Lidocaine (1%) or bupivacaine (0.5%) without adrenaline.
• Metzenbaum or iris scissors.
• Forceps.
• Straight arterial clamp or hemostat clamp.
• Vaseline gauze or Bactigras.
• Absorbable suture material.

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Site Preparation

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Anesthesia: Digital Nerve Block

1. Injection at the Base of the Digit:
   • Insert the needle at a 45° angle on the lateral side of the digit, just proximal to the web space.
   • Inject 1-2 mL of lidocaine while withdrawing the needle slightly.
   • Redirect the needle to the palmar/plantar surface of the same side and inject 1-2 mL.
2. Repeat on the Opposite Side:
   • Move to the other side of the digit and repeat the same process.
3. Confirmation of Anesthesia:
   • Wait 5-10 minutes for the anesthetic to take effect.
   • Test the anesthesia by gently pinching the digit or using a blunt instrument.

Comment Section:

Nail Removal: Total/Partial Extraction

1. Inspect the Nail Bed:
   • Check for lacerations or other injuries.
   • Suture any lacerations with absorbable material if necessary.
2. Perform Total/Partial Nail Extraction:
   • Use Metzenbaum or iris scissors to gently insert under the nail between the nail plate and the nail bed.
   • Carefully advance toward the nail base, separating the nail from the nail bed.
   • Use the hemostat or arterial clamp to grasp the nail and remove it completely.

Wound Closure and Dressing

1. Cover the nail bed with Vaseline gauze or Bactigras.
2. Secure with a sterile dressing.

Post-Procedure Care

• Advise the patient to keep the dressing dry and intact.
• Schedule a follow-up visit for wound assessment.

Score Sheet