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UBC Objectives: Surgical + Procedural Skills & Procedures: I&D, wound care, suturing, biopsy, cryo, cautery, skin scraping/paring, subungual hematoma + paronychia drainage, toenail excision, foreign body removal, local anesthesia

5/4/2018

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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
  • Perform minor surgical procedures and wound closures

While in clerkship, and so far in residency, I have had the opportunity to perform minor surgical procedures and wound closures on multiple occasions. My reference of choice is Procedures Consult.

Abscess Incision & Drainage
An abscess is a walled off collection of pus, relatively impenetrable by antibiotics floating in the bloodstream. For this reason, to treat it, it often needs to be incised and drained, to remove the bulk of the gunk and allow the body to heal the remainder. If the abscess is located in the dermis, the layer of the skin just deep to the superficial skin layer (aka epidermis), this is typically an in-office procedure that can be done in any general practitioner's office. In a purulent skin abscess, the causative agent is usually MRSA (methicillin-resistant Staphylococcus aureus), though in patients who are immunocompromised it is possible that there are other microbial culprits. Consider taking a culture of the abscess fluid in unusual circumstances.

Equipment:
  • Local anesthetic (1% to 2% lidocaine)
  • Syringe with 25- to 30-gauge needle, usually ½ to 1 inch, because only the skin over the abscess is anesthetized
  • Chlorhexidine
  • 4 × 4-inch gauze
  • No. 11 blade
  • Curved hemostats
  • Sterile cotton-tipped swabs (optional, to explore the abscess cavity)
  • Possibly iodoform packing gauze (¼- to ½-inch width and up to 24 inches long, depending on abscess size)
  • Possibly culture materials
  • Bandage scissors
  • Dressing of choice

Procedure:
  1. Obtain consent (ensure patient wants to have the procedure done after a discussion of the risks and benefits of the procedure, as well of the alternative options, including the option to do nothing). Risks of the procedure are as follows:
    1. Failure to resolve, causing cellulitis, osteomyelitis, or progression to septicemia
    2. Recurrence
    3. Formation of a fistula
    4. Scar or keloid
  2. Position the patient so that the region with the abscess is well visualised and supported with the patient in a relaxed position
  3. Don personal protection (gloves, gown, mask, eye protection)
  4. Clean the skin overlying the abscess with chlorhexidine
  5. Perform a superficial field block with a local anesthetic. The goal here is to freeze the overlying skin, not the deep tissue containing the abscess. Note that quite a bit of local may be needed as the acidic environment of an abscess makes the anesthetic less potent.
  6. Once the overlying skin is frozen, make an incision, ideally with the lines of skin tension for better healing. If a culture of the fluid is to be taken, be sure to collect it from the contents of the abscess without contamination by contact with superficial drainage. Ideally, however, if a sample is intended to be sent for culture before it is incised, it is more ideal to collect a sample of the walled off fluid before incision with a large bore (18-gauge) needle.
  7. Express as much pus as can be reasonably done.
  8. Using the hemostats +/- sterile cotton-tippled applicators, explore the abscess pocket to be sure there are no leftover walled-off fluid collections. If present, gently break them open and drain the contained pus.
  9. Pack the empty pus pocket with packing material (in a larger surgery as done in the OR, a drain may instead be inserted). After packing, leave a small end of gauze protruding from the wound, which will serve to drain the fluid from inside to out. Then the wound can be dressed with a sterile dressing and with a layer of ointment (or by using a nonstick dressing) so that the packing material doesn't stick to the dressing and get pulled out accidentally when changing the gauze, as may need be done frequently depending on how much purulence their is. Keeping the wound clean and dry is best.
  10. Every few days, the patient can have their packing gauze reduced. Depending on the patient, they may be competent to do this themselves, or they may need to have followup for this with a healthcare professional. Every time, about 2 inches can be pulled out and cut off, leaving a tail of packing gauze protruding from the wound each time like the first time it was packed. The wound should be dressed just like it was after the incision and drainage.

Postprocedure advice:
After the procedure is done, the patient should be advised to watch for, and seek medical attention, if any of the following signs develop:
  • Recollection of pus in the abscess
  • Fever/chills
  • Increasing pain, swelling, and redness
  • Red streaking near the abscess
If patients are experiencing pain after the local anesthetic wears off, they can be advised to use acetaminophen +/- an NSAID as needed. They should also encouraged to bathe/shower as they wish, simply making sure to change the wound dressing afterward.

Wound debridement
To debride a wound means to remove dead tissue and foreign material from it. It is an important aspect of proper wound care to prevent infection, restore function, and improve cosmesis. All wounds must be examined for the need for debridement; depending on the history and physical exam, this need can be not at all or extremely compelling, with higher suspicion if wounds have a more traumatic or dirty mechanism of injury.

Equipment:
  • Sterile gloves
  • Sterile surgical towels and/or fenestrated drape
  • Face mask
  • Sterile gauze
  • Scalpel with a No. 15 blade
  • Tissue scissors
  • Hemostats
  • Small tissue forceps
  • 19-gauge plastic catheter or needle and 35-mL syringe for irrigation
  • Splash shield for irrigation syringe
  • Sterile saline for wound irrigation
  • For wounds in hair-bearing regions: petrolatum jelly or water-soluble ointment and/or small scissors to remove hair
  • Good lighting source
  • Tourniquet (may be needed if bleeding is not controlled)
  • Non-adherent dressing material
  • Absorbent dressing material
  • Outer wrapping for dressing 
  • Topical antibiotic preparation (optional)
  • Supplies for local or regional anesthesia

Anatomy:
Skin is made up of 3 layers: the epidermis, the dermis, and the subcutaneous tissue. Below the subcutaneous tissue lie the fascia, bones, muscles, tendons, etc. This is a diagram from Procedures Consult showing the different layers of the skin, and a very well clean wound that has either already been debrided or that appears as though it doesn't need any debriding. 
Picture
Procedure:
  1. Obtain patient consent (such that they choose to have the procedure done after you've assessed their understanding of the risks vs benefits of the procedure, and how it compares to the alternative options, including the option of doing nothing).
  2. Observe universal precaution (gloves, gown, mask, eye protection) - just imagine how any patient you will be working on could have a serious blood-borne illness such as HIV
  3. Position the patient so that they are comfortable and with the wound well-exposed and well-supported. You want to make sure you can sit (ideally) or stand comfortably and ergonomically to do your work. The laceration should be well lit and needed equipment should be within easy reach.
  4. Before anaesthetising the wound, exam the distal or surrounding area of the body for neurovascular integrity.
  5. Anesthetize the area
  6. Cleanse the wound. This should be done as soon as possible after injury so as to remove bacterial and material contamination. Irrigate thoroughly. Although there is no evidence-based recommendation for how much to irrigate, a rule of thumb is 30-50 mL for every square cm of laceration. Regardless, continue to irrigate until all visible debris has been removed. Using warm irrigation solution is ideal for patient comfort. Making sure to clean and scrub the surrounding tissue, if needed, is also important, to prevent spread of the contamination into the wound.
  7. After cleaning, disinfect the skin surrounding the wound (do not get disinfectant inside of the wound itself) and drape the wound to create a sterile field. Employ sterile technique now, with sterile gloves and sterile instruments. 
  8. Explore the wound carefully to be sure there is no remaining debris. Examine for damage to deep tissue. Bleeding should be adequately controlled with local anesthetic containing epinephrine +/- the use of a tourniquet.
  9. Identify and debride any devitalized or necrotic tissue with a scalpel or small iris scissors. Debridement technique may be modified depending on how the tissue is planned to be reapproximated, such as based on suture technique and natural lines of skin tension.
  10. Reirrigate the wound to remove any remaining tissue debris.
  11. If the wound is to be closed, it would then be done at this time, followed by proper wound aftercare. 

Insertion of sutures; simple, mattress, and subcuticular
Sutures are the most common way of closing wounds, and the closest I'll ever get to being a good housewife. Before beginning to suture, proper wound debridement needs to be done (as above). We suture skin to restore it's function and improve cosmesis (less scar tissue compared to healing by secondary intent). We do not suture skin closed if there is significant risk for contamination, because this increases the risk of infection, but usually this can be mitigated by good debridement.

Equipment:
  • Skin cleansing agent, such as chlorhexidine 
  • Sterile gauze
  • Local anesthetic
  • 5- or 10-mL syringe
  • 25-gauge needle for anesthetic injection
  • Saline solution
  • 30- to 60-mL syringe with splash guard for irrigation
  • Sterile bowl
  • Sterile drape
  • Needle holder
  • Toothed forceps (Adson Brown)
  • Suture scissors
  • Suture material
    • Many choices here. Most commonly used is Vicryl for deep absorbable sutures and Prolene for superficial nonabsorbable sutures.

Anatomy of wound healing, completed quoted here from Procedures Consult because I don't like to make my life harder than it needs to be:
  • Once a wound is closed, the initial phase of wound healing during days 0-5 is the inflammatory phase, during which coagulation begins and inflammatory cells, such as neutrophils and macrophages, are recruited.
  • These inflammatory cells “clean” the wound with proteolytic enzymes, ingest microorganisms, and recruit fibroblasts.
  • The epithelium is the only structure to regenerate during wound healing; this begins immediately after the wound is closed, during the epithelial phase.
  • Within 48 hours, the epithelium regenerates and closes off the external surface of the wound to protect it from contamination. During this time, the wound is very fragile and has little tensile strength, relying mainly on external repair techniques to maintain closure.
  • The fibroblast phase begins around 48 hours after injury.
  • Fibroblasts that were recruited during the inflammatory phase synthesize and deposit collagen. The formation of collagen gives wounds their strength.
  • Collagen production reaches its peak about 7 days later and has the most mass at 3 weeks after injury.
  • The wound will continue to strengthen over the next year.

Procedure: 
  1. Obtain consent (same idea as above). Risks to make sure patient is aware of:
    1. Infection
    2. Scarring
  2. If loved ones want to be present, ensure they are seated for the procedure, and be sure there is a nurse who can attend to them if they feel funny.
  3. Protect yourself before you wreck yourself (sterile gloves, gown, mask, eye protection)
  4. Document neurovascular exam (as above)
  5. Anesthetize the region to be sutured (to be discussed)
  6. Position patient (as above)
  7. Prepare wound including debridement, as indicated (as above)
  8. Suture (see video below)
  9. Postprocedure wound care (as above) [Consider need for tetanus prophylaxis depending on risk from mechanism of injury and patient's immunization status]
  10. Document (at the endow any procedure, although not explicitly mentioned in the procedures above; it's just always the standard of care)
Laceration repair; suture and gluing
There are some situations in which a laceration can instead be repaired with a tissue adhesive (aka, skin superglue). When this is a feasible option and there are no contraindications, this can make closing a wound a super easy task, and it also typically means less scar formation. It is also pain-free and super cheap. Pretty much, when it can do the job, it is to everyone's advantage to use it over other methods of wound closure. 

So, when can we do this already? UpToDate recommends it for lacerations that are clean, that can be well-approximated, that are under low tension, and that are under 4-5 cm in length. It is particularly useful for fragile skin that cannot be sutured easily, common in the elderly patient. In wounds that are under too much tension such that the wound could dehisce using adhesive alone, deep subcutaneous sutures can be employed to relieve tension and allow the adhesive to close the superficial tissue (something to consider in cosmetically important areas).

The contraindications, per UpToDate, of using tissue adhesives for laceration repairs are: 
  • "Wounds under tension, unless deep sutures are placed to permit wound approximation 
  • Lacerations of the hands, feet, or joints, unless immobilized
  • Complex stellate lesions, crush wounds, or other lacerations with poor wound approximation
  • Oral mucosa or other mucosal surfaces (ex: vagina) or areas of high moisture such as the axillae and perineum
  • Wounds in hairy areas unless the hair is trimmed
  • Wounds requiring a high level of precision (ex: hairline or vermilion border)
  • Bite wounds and other wounds at increased risk of infection (ex: puncture wounds, wounds with devitalized or contaminated tissue)
  • Wounds in patients with allergy to adhesives (or formaldehyde), bleeding disorders, or comorbid conditions that delay or prevent proper healing

Procedure: The basics of the procedure are similar to the above procedures, in that the following elements must be included: consent, personal protection, patient positioning, wound irrigation +/- debridement, neurovascular examination, and documentation. The procedure itself is extremely simple, easily demonstrated with this UpToDate figure:
Picture
Aftercare is very simple. The sealed off laceration does not require a dressing, as it serves as its own water-resistant bandage. If glue gets on non-lacerated skin, it can be wiped off rapidly or if on the skin for greater than 10 seconds, it can be removed with the help of petroleum jelly. It usually peels off as the tissue heals over the next 5-10 days. Just like with placement of sutures, patients should return for medical care if any signs of infection develop, or if there is wound dehiscence. Otherwise, no further followup care is needed. Easy peasy lemon squeezy.

Skin biopsy; shave, punch, and excisional & Excision of dermal lesions, ex: papilloma, nevus, or cyst
Skin biopsy procedures can be useful for for diagnosing and treating various skin lesions. There are various techniques to select from, most commonly being shave, punch, or excisional approaches. The least traumatic method is the shave biopsy, as it only removes tissue protruding above the epidermis, removing epidermis and ideally limited dermis in the process. Naturally, then, this is insufficient for lesions that extend into the dermis, and it is absolutely contraindicated if the lesion being biopsied could possibly by melanoma (in which case the pathologist needs a deep dermal sample). If a shave biopsy won't "cut" it, then there is the option to do a punch biopsy, which is an easy way to gather a deep biopsy/tissue removal. These can remove between 2 and 5 mm in diameter of tissue, based on the size of the punch that is selected. These are great because they are just super easy to perform and if less than 4 mm, and sometimes if less than 5 mm, suturing the site closed is usually unnecessary. If neither of those two options suffices, using a good old-fashioned scalpel to perform an excisional biopsy is always a dependable technique.

Equipment (varies depending on the technique):
  • Nonsterile gloves (sterile gloves and drapes are needed if sutures are to be placed) 
  • Skin antiseptic (ex: chlorhexidine) or alcohol wipes (if not placing sutures)
  • Local anesthetic (0.5 to 1 mL of 1% to 2% lidocaine with or without epinephrine), syringe with an 18-gauge needle for drawing medicine from the anesthetic vial, and a 27- or 30-gauge needle for injection.
  • Specimen container, usually containing formalin (alternative transport medium required for culture)
  • Surgical marking pen.
  • Scalpel handle and blade OR 3- or 4-mm punch biopsy tool OR a single-edge flexible razor blade or scalpel blade (No. 10 or 15)
  • Tissue forceps
  • Sharp fine-tissue scissors
  • Suture kit or Steri-Strips. Sutures or Steri-Strips are needed only if the biopsy site measures 4 mm or larger. Absorbable sutures (ex: Vicryl) may be needed for larger incisions.
  • Antibiotic ointment.
  • Adhesive bandage.
  • Hemostatic agents (Monsel’s solution, aluminum chloride, or gel foam)

Procedure (in general, technique varies depending on specific method): Consent, positioning, clean or sterile technique, personal protection, planning biopsy (ex: for an excisional biopsy, plan to excise parallel to lines of minimal skin tension, outline area to be biopsied), anesthesia, remove tissue, control bleeding +/- suture, wound aftercare (as above).

*Note that the picture under the "Wound debridement" section above is what an excisional biopsy would look like after the tissue has been removed.

Cryotherapy of skin lesions
I debated even including this procedure in this section as a minor surgical procedure, but I opted to include it because it's useful to consider as an alternative strategy to surgical lesion removal, if appropriate for the type of lesion. It is much less invasive, almost always pain-free, and convenient to do in the clinic. It is commonly used instead of surgical biopsy for removal of the following sorts of lesions: warts, molluscum contagiosum, skin tags, papular nevi, and seborrheic keratoses. One of the downsides of this technique is that it can leave scars on people if they have darker skin pigment (but not in fair individuals), and you should think twice about doing it in patients who have chronic infection or who are otherwise immunocompromised because they may have more cryoglobulins floating around in their blood, and through some mechanism, this can lead to greater scar formation. You also want to make sure you're not freezing an area with a high degree of cutaneous nerves (may damage the nerves and lead to a permanent loss in sensation) or in which there is not the greatest source of blood supply to promote good healing (ex: lower legs in a patient with long-standing poorly controlled  diabetes mellitus).

Equipment = freezing agent
  • Freezing agents can come in a smorgasbord of different vehicle options, and getting familiar with your applicator will be important to perform the procedure effectively. Most clinics use liquid nitrogen, but there are other agents that can be used such as nitrogen oxide and other refrigerants.

Procedure:
  1. Obtain consent (the reason for doing it, what "it" entails, risks as outlined above, comparison to alternative options such as biopsy, with discussion of option to do nothing)
    1. ​Let the patient know that there will be burning sensation when the freezing agent is applied and then when it thaws seconds after. This will sort of feel like an ice cube stuck to the skin. This often reassures them that the pain is not all that intense. For people who are scared of this feeling, consider options for freezing (this can be as basic as simple cooling skin of the skin with ice, which is not really strong but may help to numb a bit, or applying a topical anesthetic, although this usually needs to be applied 60 min prior to have a decent numbing effect). Injecting local anesthesia would defeat the purpose, because this is more painful than cryotherapy itself. 
  2. Prepare site prior to frozen, if indicated (with highly keratinised tissue as is common on the plantar surface of the foot, you may need to pare back some of the thick overlying skin to allow better access of the freezing to the target).
    1. The patient can help prepare a plantar wart by applying salicylic acid for 2 weeks prior to freezing in clinic. After cleansing the area, the patient can apply an over the counter solution of salicylic acid. Alternatively, the patient can use a salicylic acid pad, cut just a little larger than the wart. This is left on for 24 hours, until changing it out for a new one the next day. If the pad keeps coming off during the day, it can be used at night only and still have a good effect. After 2 weeks, when the patient present to  clinic for cryotherapy, a soft white layer of keratin can be peeled away to reveal the base or root of the plantar wart lesion. In lesions with significant keratin, a No. 10 or No. 15 scalpel blade can be used to shave off the keratin in thin layers until the first red punctate vasculature is seen (verruca). Stop debridement at this point to minimize bleeding. 
  3. Position patient for their comfort but also for yours and to be able to see your work. 
  4. Freeze (Good rule of thumb is to shoot to freeze for 5-10 seconds depending on degree of overlying keratinised tissue).For resistant lesion such as warts, do a freeze/thaw/freeze cycle. Freezing should extend about 2-3 mm outside the border of the lesion. 
  5. Let the patient know that the development of a blister or scab is normal following the procedure. This should heal as any other scab does. If the lesion has not been completely removed, can repeat above every 1-3 weeks.

*Note that for common warts, the combination of patient-applied salicylic acid and physician-applied cryotherapy is standard practice. While this could also be done for genital warts, generally different strategies are employed. Good first-line options include
  1. Patient self-treatment with imiquimod (5%) cream 3 times weekly until there is clearance, for up to 16 weeks of treatment
  2. If patients cannot reach warts or there is no or minimal effect by 6 weeks, physician-applied trichloroacetic acid is second-line. Note that in a pregnant women who wants to treat genital warts, TCA is first line (although treatment of genital warts can usually wait until after delivery).
  3. Laser and cryotherapy are next line options.
  4. Consider biopsy to exclude precancerous or cancerous lesions if patient is immunocompromised or postmenopausal, when the lesions are visually atypical, or when warts fail to respond to standard therapy.

Electrocautery of skin lesions
Although I've only seen cautery being done in the operating room, this is a modality that can be employed in the office setting. It can be useful to remove moles, with the advantage of better hemostasis and so can be a good option when there is a greater risk of significant bleeding. It is also useful for getting rid of annoying spider veins and telangiectasia. 

Equipment:
  • Alcohol wipe
  • Local anesthetic
  • 1-mL syringe with 30-gauge needle
  • Electrosurgical unit (ESU)
    • This must include a smoke evacuator (HPV and HIV have been detected in smoke from this procedure)
    • Various electrode tips (depending on procedure), reusable or disposable
    • Antenna (or grounding) plateHandpiece for electrode tips (devices can be finger activated from the handpiece)
    • Foot pedal to activate the handpiece (useful for delicate surgeries to avoid compromising hand precision trying to also activate the device)
    • Movable cart
  • Mask
  • Nonsterile gloves
  • Silver nitrite (or Monsel's solution if not working on the face)
  • Antibiotic ointment
  • Adhesive bandage

Procedure: Proper technique will depend in part on knowing how to use the device you will work with. Basic settings range from "cutting," "cutting and coagulating" or "cut and coag," and "coagulation." Basically, there is more hemostasis toward the coagulation setting side, but also more scarring (although if too low for the tissue being worked on, this could lead to less smoothness in the cut, and a more unsightly scar). The intensity of the electricity can also be adjusted to modify the power of the instrument,  so it can be tuned for the procedure to be effective while also limiting any excess force. This is a procedure that requires proper training and practice. Preparation before and care after the procedure is much the same as for other lump and bump procedures (see above).

​Skin scraping for fungus determination
This wannabe procedure involves a scalpel, so I'd say it "makes the cut." It was also lovely to encounter the description for this simple yet useful procedure in the Canadian Family Physician, the journal I read the most. The article is called, "Microscopic Potassium Hydroxide Preparation" and it was published in 2014 as part of a series called, "The Top Ten Forgotten Diagnostic Procedures," an initiative to teach family medicine residents about useful diagnostic procedures that are on the brink of extinction. Makes sense, I have only seen this procedure being done very rarely despite the multitude of times there's a diagnostic dilemma regarding yeast vs something else. I think the thinking is that empiric treatment with antifungals is of such little harm, it's okay to just give it a go without really knowing. But this can lead to treatment failure, onerous application and cost of antifungal therapies, and a delay in resolving the problem if it is not in fact a fungal infection. Of course, some fungal infections will clinically be very convincing of this, in which case this procedure would not need to be done. But, for those times in which there is diagnostic uncertainty, it makes a lot of sense to me to check a scraping for fungus under the microscope in real-time to inform clinical decision-making. Note that the use of a Wood's lamp is an alternative procedure that can be done before opting to do a scraping. 

Equipment: 
  • Small scalpel blade
  • Microscope slide and cover glass
  • 20% potassium hydroxide (KOH)
  • Gauze
  • Microscope with 10 × and 40 × objectives

Procedure: 
As always you start with obtaining consent, and then gather equipment, position and drape the patient, and don personal protection. There is no aftercare needed for this procedure, but if the procedure does not reveal evidence of fungal infection, you should send the scrapings for fungal culture in case the sample collected is just not representative. Here is the meat in the middle:
  1. Collect scrapings of the area of interest. This can be done very gently with a scalpel blade, possible with a blunter object such as a tongue depressor if the patient is not very cooperative.
  2. Place the specimen on a clean glass slide. Add 1 drop of 20% KOH.
  3. Place the cover glass on top of the slide and gently press to get rid of any air bubbles. Blot excess solution from the finished slide preparation with the gauze.
  4. Place slide on the microscope stage and start with a low-power (10×) examination. To make epithelial cells visible, reduce illumination by lowering the condenser.
  5. Examine for fungal structures such as hyphae or yeast. If any look suspicious, use the 40 × setting (high-dry objective) to investigate further, as hyphae or budding yeast suggest fungus

The article provides this photo of a positive finding under the microscope:
Picture
​Subungual hematoma release
Subungual hematomas aren't a significant concern, at least by themselves, but they can hurt like a B and if large, could suggest a fracture of the underlying bone in the finger or toe. For any significant hematoma, getting an xray before trephination would be the way to go. It's also only really helpful if a patient presents within 48 hours of when it began, as there is no evidence to show that trephination after this time makes a difference at all. Trephination should also not be done by the general practitioner if there are any complicating features, such as signs of infection, extensive nail-bed injury, or evidence of fracture. These patients should extend get a referral to a hand surgeon. Here is an example of a subungual hematoma that could be safely decompressed by the general practitioner, ideally from the distal end of it so as not to risk damage to the lunula (part of the nail bed matrix).
Picture
Equipment:
  • Electrocautery device or insulin syringe 

Procedure:
  1. Consent, patient prep, and putting on personal protection. You know the drill.
  2. Perform a complete neurovascular examination of the digit along with examination for any injury to the extensor tendon. Inspect for nail fold disruption or signs that the hematoma is not just a simple hematoma.
  3. Trephinate to open the subungual space. (Pretty much making a hole in the nail.)

Drainage acute paronychia
The information in this post gets credited to a fabulous Emergency Medicine website called Life in the Fast Lane.  Some gold nuggets by the Emergency Medicine Nurse who wrote the post:
  • Paronychia is an inflammatory involvement of the fold of the nail. 
  • Pus, erythema and swelling develop between the nail and nail fold causing throbbing pain and discomfort.
  • The most common cause is direct or indirect trauma to the cuticle or nail fold.
  • The most common organism involved in paronychia is Staph aureus

Equipment: Whatever you need to perform a digital anesthetic block (procedure to be explained, stay tuned), a scalpel, gauze, saline, a syringe and any associated supplies for irrigation, and a bandage +/- antibiotic ointment.

Procedure: All the usual, and then following:
  1. Drain the paronychia by making a longitudinal incision parallel to the nail edge across the nail fold to release the pus, under a ring block anesthetic.
  2. Mop out the cavity
  3. Soak the digit in a saline solution and irrigate away any debris. Then dress the digit with an antibacterial or simple dressing.
  4. There is no evidence that antibiotics are any better than incision and drainage, but patients with severe paronychia with tracking cellulitis require admission for intravenous antibiotics. For patients not admitted for intravenous antibiotics, consider discharging them home on oral antibiotics, with encouragement to elevate the affected digit. Ideally they should have the area inspected by a healthcare professional in 24-48 hours after the procedure is done.

Now just imagine this was a patient who came to you, and you can do something to make it better right away! Brilliant.
Picture
Partial toenail removal; Wedge excision for ingrown toenail
For whatever reason, these are listed as separate procedures under the list of core procedures that I am expected to be able to perform as a family physician, although the latter is really a reason (and probably the most common one) to do a partial toenail removal, so I have  lumped them together here. The other common reason would be to clip nails shorter when trying to debride a toenail of onychomycosis (toenail fungus), but in this setting, the procedure is as simple as trimming a nail as short as possible (the part with fungus doesn't have as much sensation, and you basically trim the nail as far back as you can while not causing pain). Another less common reason to trim a nail back is in the setting of trauma and partial traumatic nail avulsion. In this setting, you would want to trim the nail back just until it is not likely to catch (if the nail is oriented in a funny direction).

Equipment:
  • Anesthesia and supplies for ring block along with adjunctive local anesthesia
  • Chlorhexidine and supplies for soaking digit
  • Blunt nail elevator
  • Nail splitter
  • Hemostat 
  • Iris scissors
  • Petroleum jelly or antibiotic ointment
  • Nonadhesive dressing and bandage +/- supplies for changing dressing at home
  • Open toed-sandal (patient's own) to wear home

Procedure:
  • Consent, gather supplies, position patient.
  • Anesthesia in a digital ring block (stay tuned), with additional local to ensure area is frozen to the max (this is a very painful procedure otherwise)
  • Soak digit in antiseptic solution, which can be done while awaiting full freezing effect. Poke under nail bed of distal digit with sharp (ex: tip of iris scissors) to ensure frozen. (Note that it is good practice to always ensure good freezing somehow before starting any procedure for which anesthetic is given.)
  • Insert blunt tool to separate the nail from nail bed (no longer ouchie because freezing), only including the edge of the nail if this is a wedge resection for an ingrown toenail, until you reach the proximal nail groove. Repeat this separation of the nail from surrounding tissue on the lateral nail fold and on top of the nail at the proximal nail fold.
  • Once the nail is bluntly separated on all three sides, a nail splitter is used to cut the nail longitudinally. The freed edge of nail is then pulled out with the hemostat, and any residual epithelium can be removed with the scissors.
  • Once the nail is removed, cover the nail bed with petroleum jelly or an antibiotic ointment, covered with a non adherent dressing, and bandage only lightly with gauze to allow for some swelling. Bleeding after the procedure is usually minimal.
  • Advise patient to keep extremity elevated for 2-3 days to minimise pain associated with swelling that can occur. The patient should also change the dressing daily for about 7 days until the skin heals over, soaking the digit in warm water to facilitate easy removal of the dressing the first one to two days post-procedure. There is expected to be a gelatinous film over the nail bed when the dressing is removed. Patients can clean this off with a cotton swab and dilute hydrogen peroxide, then reapply the lubricant of choice and nonstick dressing/gauze wrap.

For all the visual learners:
Picture
Removal of foreign body, ex: fish hook, splinter, or glass
If there's something alien that is penetrating your skin, it's best to eject it from the mothership. Foreign bodies can obviously be painful, but they can also pose a serious risk for infection. Naturally, living in Canada means lots of splinter injuries with all the lumberjacks hard at work (:D), but now that I'm out on the West coast, fish hooks are also a thing (and beware of the ones with barbs on the end, tricky little buggers). Being in the downtown East side means I also need to be on the lookout for shattered glass. Okay I'm being lame, but these are three common types of foreign bodies that can inadvertently get under the skin from trauma. This year, I pulled out a piece of tree from a snowboarder who crashed into the bush while carving his way down Cypress mountain. He came into his family doctor's office for this, not the emergency department, so you just honestly never know what might walk in the door.

Really, foreign body removal is part of the process of good wound debridement (see above), so I won't belabour the topic here. It is important to highlight the need to ensure tetanus prophylaxis whenever a wound is penetrated by a foreign object. As well, if a patient complains that a wound feels as though something is in it, heed that sensation; if nothing can be seen, a plain xray can be your friend - even glass is radiopaque as long as the shards are larger than 2 mm. And while xrays are friendly, anesthesia is even friendlier - a digital ring block can make all the difference to ensure proper wound exploration under proper lighting +/- magnification. Irrigating with drinkable tap water is just as good as saline, and better in the possible dirty wound (per the mechanism of injury on history) because the pressure with saline syringe irrigation can further embed foreign material. 
Picture
...Sorta worth a splinter or two.

Pare skin callus
Calluses and corns and common benign skin thickenings on the feet that are physiologic adaptations increased pressure to that region of the body. Often, they arise because or poor-fitting shoes, abnormal gait, or underlying bony problems (commonly neuropathic joints as a complication of long-standing and poorly controlled diabetes). Sometimes corns in particular can be a bit difficult on first glance to differentiate from a wart, but you'll notice that warts obscure the natural skin lines ("toe prints" if you will), while these lines tend to be more pronounced with purely hyperkeratotic skin. After paring them down, you'll also see an absence of the dark specks normally within the central area of a wart (these are punctate capillary thromboses; the wart virus basically causes small clots in the surrounding capillaries).

Equipment:
  • No. 15 scalpel blade
  • Salicylic acid plaster/ointment
  • Supplies for the dressing/dressing changes

Procedure:
  • Along with all the other procedure basics (consent, documentation, and everything in the middle), the gist of corn or callus treatment is debulking it with a scalpel (this is not at all painful because this skin is keratinised epithelial cells, which does not have any nerve endings) and then applying salicylic acid treatment until the remainder of the hyperkeratotic skin has sloughed off. (Note that the use of salicylic acid therapy is contraindicated with patients with decreased sensation to the area - if the applied acid patch shifts and the patient doesn't feel this, it could lead to damage to perfectly healthy tissue)
  • After being debulked with a scalpel, that first application of salicylic acid should be undisrupted ideally for 2-3 days straight, so the affected part of the foot will need to be kept dry so the salicylic acid continues to stay and work at the site. After this 2-3 day period, the patient can return for one another bout of skin paring. After this, the patient can continue to manage at home with daily salicylic acid and nightly removal with filing or pumicing any residual raised skin. The corn/callus should be resolved by two weeks after initial therapy; if not, the patient should return to see their treating physician. 
  • For lesions that recur or that or recalcitrant to the above therapy, consider ordering an xray to look for underlying bony deformities 
Picture
Infiltration of local anesthetic
Finally, I will now go over the basics of how to provide local anesthesia. The only absolute contraindication to giving a patient local anesthesia is a history of previous allergic reaction to anesthetic, which is extremely rare, but you should always ask, just as when prescribing any other medication.

Equipment: 
  • Personal protective equipment: gloves (nonsterile), mask, eye protection
  • Antiseptic solution (ex: chlorhexidine)
  • Syringe (10-30 mL, depending on how much local is needed)
  • An 18 gauge needle for drawing up the anesthetic
  • A 25-30 gauge (2.5-3.75 cm long) needle for injecting the anesthetic
  • Local anesthetic of choice (ex: 1% lidocaine with epinephrine)
    • Consider using 2% rather than 1% lidocaine when the area needing anesthesia is in a limited space that cannot afford as much intradermal solution in order to achieve the same degree of freezing effect. Conversely, a 0.5% lidocaine solution is available when greater area is needing to be anesthetized and there is concern that the maximum dose of anesthetic would be exceeded before properly freezing the full extent of what is needed.
    • Maximum dose of 1% lidocaine with epinephrine is 7 mg/kg (4.5 mg/kg without epinephrine). Always figure out maximum allowable dose prior to starting for the patient in front of you.
    • Bupivacaine has a longer duration of action compared to lidocaine, but it is limited by the maximum allowable dose, which is much less than lidocaine at 3 mg/kg with epinephrine or 2 mg/kg without epinephrine. It would probably be nice to use if only a small quantity of freezing is needed. Bupivacaine 0.25% = lidocaine 1% in strength.
    • The old rule of thumb was never to use epinephrine for "nose, toes, fingers, ears". This theoretical myth has been debunked in clinical trials, and specialists who operate regularly on these body parts use epinephrine when anesthetizing them.

Procedure: 
  1. Obtain consent (this should include warning patients about the short burning sensation that occurs when the anesthetic is first deposited, and that it is normal to feel ongoing pressure but not pain during the procedure)
  2. Position patient supine or seated comfortable (some patients can get vasovagal and faint, so they should be in a position that would allow them to faint while protecting them from falling over should this occur)
  3. Don personal protective equipment and gather other needed supplies
  4. Consider what can be done to improve patient comfort. Some tips include:
    1. Don't draw up the anesthetic from the bottle with the large bore needle in front of the patient. The size of this needle may scare them (note that the needle used to deposit the anesthetic in the skin is much smaller). 
    2. Warm the anesthetic to room temperature and buffer with bicarbonate to decrease burning sensation on injection.
    3. Freeze the skin with ice or a cold pack prior to injection (in kiddos, an EMLA topical anesthetic patch can be put on an hour before the procedure to numb the skin)
    4. Inject slowly and use smallest quantity needed (but not so much that you may compromise good anesthesia)
    5. When freezing wounds, inject into the already traumatised tissue rather than puncturing nearby undamaged tissue. When multiple injections are needed, insert the needle into previously anesthetized areas whenever possible.
  5. Cleanse the skin
  6. Inject the anesthetic
    1. Insert the needle as deep as needed, and before pushing on the syringe to infiltrate the area with anesthetic, first withdraw to ensure you have not entered a blood vessel (much greater risk of toxicity when injecting into the bloodstream rather than the surrounding tissue).
    2. Then, deposit the anesthetic while at the same time withdrawing the needle (this also prevents depositing the anesthetic into a blood vessel).
  7. Wait for the anesthetic to take effect (about 1 minute for lidocaine, and 5 minutes for bupivacaine)
  8. Test that the anesthesia is sufficiently effective (pin prick or gentle forceps pinch). If not, add more (watching your maximum allowable dose)
  9. Dispose of all sharps (I haven't explicitly talked about this in the above procedures, but this is also a standard step in any procedure containing sharps, such as scalpels and suture needles. There are special yellow containers for sharps in all healthcare facilities.
  10. Include anesthesia details in any procedure note (note what choice of anesthetic was used and how much of it was deposited)

*Although highly unlikely, it may be useful to know that phentolamine is an antidote and can be used to reverse the effects of lidocaine if ischemic complications develop. This would be extremely rare. I have never heard of this being done, and have never even been taught that this is something I should know by any attending physicians with whom I have trained to give local anesthesia.

Digital block in finger or toe
Performing a digital block is an alternative method of providing local anesthesia when performing procedures on fingers or toes. It is a method of providing sufficient anesthesia to an area that is limited for space to deposit enough anesthetic agent for sufficient freezing. The procedure and equipment needed is much the same as for providing standard local anesthesia. 

The technique for performing a digital ring block using the two-injection dorsal technique is as follows: 
  1. Pronate the patient's had with fingers extended
  2. From the dorsal aspect, insert the needle at the border of the metacarpal head.
  3. Raise a small wheel with anesthetic, then advance the needle anteriorly and slowly until resistance is felt at the palmar dermis (or needle tip causes a bulge on palmar side). Inject 2-3 mL of local here.
  4. Withdraw the needle while depositing another 1 mL of anesthetic.
  5. Repeat at the other border of the metacarpal head of the same finger.
  6. Document cap refill and gross neurological exam before and after performing the ring block.

Incise and drain thrombosed external hemorrhoid
Left until the "bottom" of this post, this is a variation of the I&D for abscesses, only it is an I&D for a blood clot rather than a collection of pus. Hemorrhoids are common, and thrombosed external hemorrhoids (painful, tender, swollen, bluish lump at the anal orifice) can be a source of significant pain, although are easily "rectified" with an in-office I&D procedure, usually done within 48 hours of onset of pain because after this the pain starts to subside anyway. In the same "vein," perianal skin tags can also be excised, although this is mostly done for cosmetic purposes as they are asymptomatic (on occasion patients may experience pruritus from them). Patients should generally be advised that this procedure, like any, is not without risk, and so is generally not recommended. 

Equipment:
  • ​Local anesthesia (ex: lidocaine 2% with epinephrine), 27-gauge 1.5-inch needle, 3 mL syringe
  • Fine tissue forceps
  • Scalpel blade (No. 11)
  • Sharp scissors
  • Mosquito hemostats
  • Antiseptic solution (ex: chlorhexidine)
  • Personal protection (gloves, gown, mask, eye protection)
  • Patient may take NSAID about an hour or so before the procedure
  • Electrocautery or silver nitrate sticks

Procedure:
  1. Obtain consent (risks include: perianal abscess, chronic fissure, perianal cellulitis, bleeding or hematoma)
  2. Anoscopy to ensure hemorrhoid originates below the dentate line (to be reviewed in another post)
  3. Personal protection
  4. Position patient in the left lateral decubitus position
  5. Cleanse the perianal area with antiseptic solution
  6. Anesthetize under the base of the thrombosed hemorrhoid with 2-5 mL of local anesthetic
  7. Using the elliptical excision approach, excise an ellipse over the thrombosed hemorrhoid and evacuate all clots and control bleeding with electrocautery or silver nitrate
  8. Postprocedure advice
    1. Sitz baths two to three times daily for 1 week.
    2. Oral analgesics, topical anesthetic cream (ex: lidocaine ointment), and gentle laxatives (ex:PEG) are helpful.
    3. A follow-up examination in 4 weeks.
    4. Preventing recurrence by treating constipation (usually the cause)
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