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Preop Considerations for Nail Pathology

- Discussion:
    - consider photographs for documentation;
    - consent should explain possibility of long term nail disfigurement;
    - instruments:
         - freer septum elevator, dental spatulas, fine hemostats, beaver blade, small currette, single and double pronged skin hooks;
    - an easy way of applying a tourniquet is to prep the patient's hand and then to apply a sterile surgeon glove;
         - cut the tip of the glove of the involved finger and roll the gloove tip proximally until it reaches the proximal phalanx, thus creating a
               digital tourniquet, as well as protecting the wound from what is often a dirty hand;
    - alteratively, make a tournequet using Penrose Drain and mosquito clamp;
         - 3/8 inch Penrose Drain is placed at distal end of digit, leaving an exposed "tail."
         - the drain is then wrapped proximally to the proximal edge of the digit, and is then secured with a hemostat;
         - the distal tail is then unwound;
    - suture: 5-0 and 6-0 chromic gut for nail bed; 5-0 prolene for nail fold;
    - anesthesia:
          - never use anesthetics containing epinephrine in the digits;
          - avoid injecting excessive amounts of anesthetic into the digit as this may cause ischemia;
          - distal wing block:
                - needs to be supplemented w/ more proximal metacarpal block;
                - injection site: just proximal to the edges of the lateral nail folds;
                - use no more than 1 cc of anesthetic on each side of digit

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