Surgery of the nail and its associated structures is always a delicate task as the nail apparatus is a unique organ that cannot be replaced by any other structure. Nail surgery is aimed at treating infections, removing tumours, alleviating pain, facilitating diagnosis, correcting or preventing deformities while ensuring the best functional and cosmetic result.
Profound knowledge of the anatomy, physiology and pathology of the nail organ as well as surgical skills and atraumatic instruments are prerequisites for successful nail operations. Careful preoperative preparation of the patient as well as consistent post-operative care are necessary. The following information will give the essentials of nail surgery, such as adequate anaesthesia, instrumentation, and complications. The most frequently performed nail operations are described focussing on techniques proven to be safe and successful. Nail avulsions, ingrowing nail, myxoid pseudocysts and subungual exostoses as well as the treatment of haematomas and nail tumours are outlined.
There are many possibilities to anaesthetise the nail apparatus but the most useful applicable for almost all cases is the proximal digital block. Plain lidocaine, or prilocaine or any other amide type local anaesthetic may be used to block the dorsal and volar/plantar branches of the proper digital nerves. Two to three ml are usually sufficient; too large a volume may interfere with blood circulation. The addition of bupivacaine prolongs the anaesthesia to up to 24 hours which may be a considerable advantage in particularly pain-sensitive patients.