Introduction to Podiatry 400905

Introduction to Podiatry (400905)

Week 7 Lecture - Part 2 - Nail pathologies

Debbie Turner
 Learning Outcomes
Outcome Learning outcomes for unit
numberc
1.
Identify the roles of podiatry in the health care setting.
2.
Define and describe the aetiology of common skin and nail disorders in the clinical
setting.
3.
Discuss the relevance of clinical skills in assessment of foot problems and historical
background of treatment including footwear.
4.
Explain and demonstrate the relevant skills in assessing dermatological, vascular, and
neurological status in the normal population.
5.
Identify the importance of lower extremity biomechanics and gait analysis in a
health care environment.
6.
Discuss and apply the framework of infection control standards in the health care
environment.
7.
Describe the management of patient data.
8.
Identify the legal and professional standards associated with documentation in
clinical settings
Nail pathologies
Nail Structure
 Assessment of the Nails

• Nails like skin can be an indicator of disease and

provide valuable diagnostic information.
• Changes in shape, contour and texture are not
unusual, but should always be noted in the
patient’s record card.
• Pain and appearance of the nail plate are the
most common cause of patients presenting for
treatment or advice
• Nails show a number of variations in pathology
• Trauma to the nails may be chemical,
mechanical, thermal – and the responses by the
tissues may be acute or chronic
Key points
 Proximal nail fold
Lateral nail fold
Eponychium
Lunula
Nail plate
Bone

Hyponychium

Nail matrix

Nail bed
 Keynotes -
Nail Structure
• Hyponychium - protection
• Eponychium (cuticle) -
protection
• Proximal nail fold
• Lateral nail fold (sulcus/ Keeps the nail in place
and in shape
sulci)
• Matrix and lunula (moon)
Areas of nail cell production
• Nail bed
• Onychodermal band
 Keynotes - Nail Cell Production
• Nail cells are produced by the nail matrix
– 2 areas – upper and lower root matrices
– + contribution from nail bed
– = 3 areas of cell production
• Nail plate – 3 distinct layers:
– dorsal
– intermediate and
– ventral nail plate

Germinative area Area of nail plate

produced
Upper root matrix dorsal nail plate

Lower root matrix intermediate nail

plate
Nail bed ventral nail plate
 Keynotes - Nail Bed

• Sterile component of the nail unit

• A highly vascular structure - lacks an underlying
subcutaneous layer of adipose tissue
• Responsible for the formation of the ventral nail
plate
• Supports the nail plate and extends from the distal
edge of the lunula to the yellow line
• Ridging between the nail bed and the nail plate:
– firmly holds the nail plate in place
– allows a larger surface area for transfer of
nutrients from the nail bed to the nail plate
• When there is separation from one another the nail
plate becomes cloudy – i.e. it appears white
 Keynotes - Nail Plate

• Composed of hard keratin

• Rectangular and flat in shape
• Shape determined by matrix and terminal
phalanx
• Thickness determined by length of matrix –
the longer the matrix the thicker the nail
– Short matrix produces fewer cells –
therefore thinner nail
• Longtitudinal and transverse curves
• Fits in nail grooves/ sulci
• Pink in colour due to underlying nail bed
 Keynotes – Nail Matrix
• Produces nail cells – 2 areas – upper and lower
root matrices
• If damaged – irreversible – permanently
deformed nails
• If destroyed – irreversible – permanent absence
of nail plate
• Determines shape and thickness of nail
• Matrix shapes and sizes vary per person - a flat
matrix will produce a flat nail and a curved matrix
will produce a curved nail
• Growth of the nail plate is directly proportional to
the turnover rate of cells in the matrix
 Keynotes – Vascular Supply

• The nail is supplied by:

– 2 branches of the plantar metatarsal artery
– 2 branches of the dorsal metatarsal artery
• Anastomose (join together) in the terminal
phalanx
 Keynotes – Nerve Supply
• Proximodorsal area of nail and nail bed – supplied by 2
small branches from the dorsal nerves –
– Superficial peroneal
– Deep peroneal
– Sural
• Plantar skin, distal area of nail bed & superficial skin
– Branches of the medial and lateral plantar nerve

• Glomus bodies and arteriovenous anastomoses –

thermoregulation of nail unit

• Nail - also richly innervated by a complex neural system

allowing tactile sensitivity and sensory discrimination
• Anatomically, the digital nerves and their divisions nearly
parallel the vascular supply to the nail unit
 Keynotes - Nail Growth
• Nail cells produced are exuded forwards –
if matrices are held close together
• As more and more cells are produced the
older ones are pushed outwards and
flattened (like toothpaste from a tube)
• As the nail grows forwards the nail vest
holds the nail in position
• The nail plate moves with the nail bed
tissues to extend unattached as the free
edge of the nail
 Keynotes - Nail Growth
 The cells near the back of the matrix have a
much further distance to travel before they get to
the free edge
 The cells closest to the eponychium are the
newest and the softest
 The cells coming from the back of the matrix end
up on top of the nail plate
 Factors influence nail growth
Paronychia
Paronychia
 Treatment of Paronychia

A moderate paronychia. Swelling and A scalpel (knife) is inserted under the skin
redness around the edge of the nail is at the edge of nail to open the pus pocket
caused by a large pus collection and drain it to relieve the pressure and treat
under the skin the infection.
 Treatment of Paronychia

Pressure is applied to the swollen area

to get the pus out after the incision was
made with the scalpel.
• Hypertrophic nail disorders
– Onychauxis
– Onychogryphosis
• Nail dystrophy
– Beau’s lines
 Onychauxis- OX

• Definition
• a uniform thickening of the nail plate without
any gross deformity
 Onychauxis

Unfortunately, some nail

conditions are irreversible:
 OX
• Clinical features
• Can affect any or all of the
nails
• May see transverse ridging
of the nail plate
• Often discoloured
• Often hard and brittle
• Etiology
• Trauma to the nail matrix
– Single major-e.g. brick
– Multiple minor- repetitive
pressure
• E.g. ill fitting footwear
• Hyper extended first
• Poor vascular supply to the
extremities
• Chronic skin diseases
 OX- Management

• Damage is irreversible therefore • TREATMENT

treatment is palliative • Reassure patient
• ASSESSMENT • Reduce nail
• Determine cause – Nail nippers
• Vascular assessment – Nail burr
• Social assessment • Check sulci
• Footwear assessment • Remove onychophosis (op) if
problematic
• Enucleate onychoheloma (OH) if
present
• Check for subungual necrosis
• If present treat as wound
 OX- Management

• ACTION/COLLABORATION
• If o.x. is confined to a single nail consider Total Nail
Avulsion (TNA) with phenolisation- a full medical
history is required
• Footwear advice- deep toe box
• Basic nail care advice- keep nail filed
• Gently remove o.p. with nail brush
• Access to podiatric care as required
 Onychogryphosis- OG

• Definition
• A thickening of the nail plate with deformity
Onychogryphosis
Onychogryphosis
OG before and after treatment
 OG- Clinical features

• Rough surface with

• Typically the nail plate longitudinal and
grows perpendicular transverse ridges
before being deformed
by footwear. • May be a large amount
• Deviation normally of subungual
towards the mid-line of hyperkeratosis.
the foot. • May present with
• Discoloured opaque – nail tuft- hyperplasia of
brown nail bed
– Subungual necrosis
 OG- Etiology

• Same as for o.x but now neglect is often

involved
• Increased shoe pressure causes increased
deformity.
• The nail may impact on healthy skin and cause
ulceration.
• This can eventually lead to immobility due to
the severe pain of walking.
 OG- management

ASSESSMENT
• Determine cause
• Vascular assessment
• Social assessment
• Footwear assessment
 OG management
TREATMENT
Empathy is essential
• Reassure the patient
• Hold the toe firmly to prevent excessive pull on the
underlying soft tissues.
• Initially trim off bulk of deformed nail with nail
• Be aware of nail tufts
• Reduce with burr
• Remove o.p.
• Check for necrosis- if present treat a wound
• Check adjacent skin for damage if present treat a
wound .
 OG management

• ACTION/COLLABORATION
• If o.g. is confined to a single nail consider Total Nail
Avulsion (TNA) with phenolisation- a full medical
history is required
• Footwear advice- deep toe box
• Basic nail care advice- keep nail filed
• Gently remove o.p. with nail brush
• Access to regular podiatric care
 Beau’s Lines

• Definition
• Transverse ridges or grooves that reflect
temporary retardation of normal nail growth

• Retrospective indicators of systemic

upset/disease/trauma.
Beau’s Lines
 Beau’s lines

• Clinical features • When transverse ridges

• Common nail dystrophy are due to repeated
• Line appears in the minor trauma then a
lunula area and “rippling” is seen.
progresses distally to
the free edge
 Beau’s lines

• Etiology
• Systemic disease
• Trauma
• Coronary-vascular
• Metabolic
• Cytotoxic drugs
 Beau’s lines
• Pathology
• Temporary inhibition of nail growth
• Management
• None- reassurance that line will grow out with
time.
Onychophosis (op)

• Localised or diffuse
hyperkeratotic tissue
that develops in the nail
folds
• Commonly seen in the
elderly population
• Often asymptomatic
 Onychophosis (op)
• Overcurvature of the nail
• Excessive treatment self /iatrogenic
• Pressure
• dry skin disorders- excema, psoriasis →excessive
desquamation and build up of skin in sulci
 Management

• Investigate the cause – address the issue of increased

pressure
• Footwear- avoid tight toe box
• Hosiery- ensure not too resrictive- look at seams
• Interdigital (i.d. )wedge
• Do not over probe- encourage patient to gently
remove o.p. with a nail brush
• Keep nail filed to correct shape- encourage patient
 Assessment of the Nails
• A number of subungual conditions may give rise to pain
under or around the nail
• It is important during the examination of the nail to
ascertain the patient’s concerns about the appearance of
the nail as it may influence the choice of treatment/
management which is undertaken

Subungual exostosis
 Onychorrhexis - brittle nails
longitudinal ridging and splitting of the nails
 Koilonychia
Spoon shaped nails -

from the Greek: koilos-, hollow, onikh-, nail), also known as spoon nails, is a nail disease
that can be a sign of hypochromic anemia, especially iron-deficiency anemia.
 Onycholysis
Separation from the free edge of the nail -

Onycholysis is a common nail disorder. It is the loosening or separation of a fingernail or

toenail from its nail bed. It usually starts at the tip of the nail and progresses back
 Onychomadesis

Onychomadesis is a periodic idiopathic shedding of the nails beginning at the proximal

end, possibly caused by the temporary arrest of the function of the nail
 Canalifomis

A nail disorder characterised by a paramedian canal or split in the nail plate of one
or more nails. Small cracks or fissures extend laterally from the central canal or split tow
ard the nail edge, resulting in anappearance likened to that of an inverted Christmas tre
e. The condition is usually symmetrical and most often affects thethumbs.
Questions?