Eponychial Marsupialisation for Chronic Paronychia Info Evidence Consent
Reviewed by Dr Kieran Hirpara, Specialist Orthopaedic Surgeon Last reviewed
Why this operation has been suggested
Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Chronic paronychia is long-standing swelling and soreness of the skin folds around the nail. It is usually caused by repeated exposure to water, such as cold water over many weeks. Bacteria and yeasts can then grow in the softened skin. We often try non-operative care first, such as hand therapy, splinting, ointments or tablets. If these have not given enough improvement, surgery may be the next step.
The operation is called eponychial marsupialisation. It means making a small opening in the skin fold at the base of the nail so the inflamed tissue underneath can drain freely. Sometimes the nail plate itself is removed at the same time. The aim is to cure the paronychia by letting the swollen tissue drain without restriction. This should settle your pain and let the nail fold heal. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate.
Before the operation
Your surgeon will examine your finger and may arrange imaging such as an X-ray, MRI or ultrasound to plan the operation. Most people need no other tests. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, the doctor who gives your anaesthetic. Bring a list of all your current medications, including ointments and tablets. Your surgeon will tell you which medications to stop before surgery and when. Do not eat for seven hours before your operation. We ask for seven hours rather than six so your surgery time can be brought forward if the theatre list runs early. Arrange for someone to drive you home afterwards. Wear comfortable, loose clothing on the day.
On the day
You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will then meet the anaesthetist, the doctor who gives your anaesthetic. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed.
You will wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery.
What the operation involves
Your surgeon makes a small opening in the skin fold at the base of your nail. This fold of skin is called the eponychium. The opening lets the swollen, inflamed tissue underneath drain freely. That drainage is the whole aim of the operation.
Sometimes the whole skin fold at the base of the nail is removed in one piece, a method known as en bloc excision. Your surgeon may also remove the nail plate itself if it is irregular or damaged, as this can help the fold heal. The inflamed tissue that makes new nail sits just under the skin fold, and exposing it allows the trapped swelling to escape.
The opening is then dressed. You will go home with the dressing on, and our team will show you how to care for the finger at your review about 10 days later.
After the operation
You will wake up in the recovery ward, where nurses keep a close eye on you while the anaesthetic wears off. Your finger will have a dressing on it, and we will show you how to look after it. Pain is usually mild for this operation, and simple pain relief is enough for most people. You can move around as normal and use your hand gently. Someone should stay with you for the first 24 hours after you get home. Your team will tell you whether you go home the same day or stay one night in hospital. Antibiotics are not needed after this operation for most people. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you.
Recovery
For the first few days your finger will be tender and a little swollen where the opening was made. This settles gradually. Simple pain relief is usually enough, and keeping your hand raised on a pillow when resting can ease the throbbing. You can use your hand gently around the house, but avoid soaking it or putting pressure on the nail fold.
The dressing stays on for about 10 days, so most of your day-to-day routine continues as normal. You can dress, cook and do light tasks once you feel comfortable. Avoid heavy gripping, wet work and anything that bumps the finger until the skin has healed over.
Once the dressing comes off at your review, the open area may still be finishing its healing. The nail fold settles over time, and any new nail grows in slowly from the base. You will know things are going well when the soreness fades, the swelling goes down and you can grip and use the finger without pain.
Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. She will guide your exercises and make a splint if you need one.
Recovery varies from person to person. Your timeline may differ, and your surgeon and therapist will guide you along the way.
What can go wrong
Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early.
Sometimes an infection around the nail does not settle with early treatment. If the infection spreads deeper into the soft tissues of the finger, you may notice swelling and redness that spread out from the nail fold, a finger that feels hot, or pain that keeps getting worse instead of easing. Call the clinic if this happens, or go to the emergency department if you feel unwell or the redness is spreading quickly.
An infection can also reach the bone of the finger. This is called osteomyelitis. It can feel like a deep, throbbing pain that does not ease with simple painkillers, often with ongoing swelling and tenderness over the bone. The finger may look red and feel warm. This needs prompt treatment, so contact the clinic the same day or go to the emergency department if the pain is severe.
If early treatment of an infected nail fold does not work well, the problem can become long-lasting. You may find the swelling and soreness around the nail keep coming back over weeks or months, with red, tender skin folds that flare up with water exposure. Bring this up at your next review so the plan can be adjusted.
The nail bed, the layer of tissue under the nail plate that the nail grows from, can also be permanently damaged if an infection is not treated well in time. You might notice the nail growing in thick, ridged or misshapen, or not growing properly at all. Mention any change like this at your review.
The operation itself carries a low risk of complications, and the chance of the swelling and soreness coming back afterwards is also low. If you notice anything worrying during your recovery, such as increasing pain, spreading redness or discharge from the opening, contact the clinic rather than waiting for your next appointment.
The complications table on this page lists typical rates if you want the specifics.
When to call us
Most recoveries go smoothly, but some signs need urgent attention. Call us if you have a fever, if the redness or discharge from the wound is getting worse, or if the pain suddenly becomes severe. Go to emergency if you have calf swelling, shortness of breath, or chest pain. Call us straight away if your finger goes numb, feels cold, or you cannot move it. If in doubt, call the clinic. We would rather hear from you early than have you wait at home.
Evidence & references
This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.
Anatomy & Pathophysiology
Cutaneous Anatomy and Functional Units
- The dorsal integument of the distal phalanx is a unique cutaneous unit characterized by the presence of the nail bed and its matrix [3].
- The dorsal covering of the interphalangeal articulations of the digits forms a unique cutaneous unit that exhibits a considerable excess of skin when the digits are in extension [3].
- The fine, tight skin of the dorsal aspect of the middle phalanx constitutes a distinct functional cutaneous unit [3].
- The palmar integument of the digits is subdivided into phalangeal units separated by digital flexion folds, with three folds for the fingers and two for the thumb [3].
- When a digit is completely flexed, the integument of adjacent phalanges comes into contact at the flexion creases, establishing areas of cutaneous contact in the form of a diamond [3].
- The sides of the diamond-shaped cutaneous contact zones do not undergo variations in length during flexion and extension movements [3].
- Incisions made along the lines of the diamond-shaped cutaneous contact zones present a minimal chance of retraction [3].
- The web spaces are formed from the union of two nonsymmetrical cutaneous surfaces [3].
- The dorsal slope of the web space has a gradual incline and its supple skin is not adherent to the subjacent region [3].
- The palmar surface of the web space is flat and precipitously interrupted, with skin that is densely adherent to the commissural skeleton [3].
- The commissural skeleton of the web space is formed by the interdigital palmar (natatory) ligament between the fingers and by the distal transverse ligament at the level of the thumb web [3].
- The distal transverse ligament at the level of the thumb web is the deepest and most mobile component of the commissural skeleton [3].
Vascular Anatomy
- The arteries of the thumb vary in both size and number, making surgical reconstruction delicate [8].
- The palmar aspect of the thumb is divided into three segments defined by the opposition, metacarpophalangeal, and interphalangeal creases [8].
- In the classical layout, the "princeps pollicis" artery crosses the first intermetacarpal space and runs along the ulnar side of the first metacarpal bone [8].
- The "princeps pollicis" artery emerges onto the subcutaneous palmar tissue at the level of the cutaneous flexion crease of the metacarpophalangeal joint [8].
- At the metacarpophalangeal joint level, the "princeps pollicis" artery divides into two terminal rami known as the collateral palmar arteries of the thumb [8].
- The collateral palmar arteries of the thumb run along the digital tunnel symmetrically and are of equal caliber [8].
- The collateral palmar arteries of the thumb head distally to finally unite in the pulp arcade [8].
- During their transit in the digital tunnel, the collateral palmar arteries break off into numerous collateral branches that are cutaneous, articular, or osseous [8].
- An arcade located deep in the flexor tendon joins the two collateral arteries at the level of the distal metaphysis of the first phalanx [8].
- Vessels originating from the subtendinous arcade at the distal metaphysis of the first phalanx enter the "vincula" and irrigate the flexor tendon [8].
- Only 15% of anatomical dissections of the palmar arteries of the thumb fall into the classical "typical" category [8].
- In the second segment of the thumb, the two arteries run alongside the flexor tendon and behind the collateral nerves [8].
- In the second segment of the thumb, the main artery is typically the ulnar collateral artery [8].
- The subtendinous anastomosis situated at the level of the neck of the first phalanx acts as a "moderator" between the two collateral arteries [8].
- In cases where the palmar ulnar collateral artery is absent, the dorsal artery takes its place by means of a branch through the subtendinous arcade [8].
- In the pulp segment of the thumb, the two arteries are of similar size and run through the thick fatty subcutaneous padding [8].
- In the pulp segment of the thumb, the arteries cross over and convert into the ends of the digital nerves at the level of the median axis [8].
- The posterior area of the thumb is vascularized by two arteries which originate from the palmar arteries at the level of the first metacarpal [8].
- These dorsal arteries run laterally along the metacarpophalangeal joint and continue obliquely from volar to dorsal before heading distally on the side of the two distal phalanges [8].
- At the level of the neck of the first phalanx, an anastomosis originating from the palmar arteries can be found on the dorsal aspect [8].
- The dorsal arteries of the thumb are joined by three arcades: one inconstant arcade under the extensor tendon at the neck of the first phalanx, the arcade of the nail matrix, and the arcade of the nailbed [8].
- The ulnar dorso-collateral artery generally stems from the "princeps pollicis" onto the medial border of the neck of the first metacarpal [8].
General Hand Architecture
- The hand consists of 19 bones, 17 articulations, and 19 muscles situated entirely within the hand [2].
- The hand contains about the same number of tendons activated by the forearm muscles as it has intrinsic muscles [2].
- The open hand, with fingers extended and in contact, forms a balanced graceful oval in its longitudinal axis [2].
- The proximal "carpometacarpal" half of the hand is flattened, presenting two faces with unique anatomical and functional significance [2].
- The posterior or dorsal aspect of the hand is convex, while the anterior, palmar, or volar aspect is concave [2].
- The distal half of the hand is separated into five digits which flex toward the palm [2].
- The digits converge in closing by flexing and adducting, and diverge in opening by extending and abducting [2].
- The thumb has a more proximal and lateral position, allowing movement inward and outward from the palm [2].
- The four fingers are the distal extension of the carpometacarpal part of the hand [2].
- The hinges of finger movements are located at the thenar crease and at the transverse distal palmar crease, not at the bases of the digits [2].
- When the fingers are extended and separated, the tips of the fingers lie on the circumference of a circle whose center is the head of the third metacarpal [2].
- The web space of the thumb is the largest and deepest among the digital web spaces [2].
Investigations
- Clinical evaluation of the hand and wrist requires combining patient history with a careful physical examination to pinpoint or narrow the scope of possible pathologic processes [1].
- Diagnostic tests such as imaging and serum laboratory studies are useful in determining pathology but can be expensive, time consuming, and often nonspecific [1].
- A careful physical examination is essential to direct care and future testing if indicated [1].
- An 8-MHz Doppler tone assessment may be used to identify superficially displaced neurovascular bundles when Dupuytren cords lie beneath soft fleshy prominences [11].
- False-negatives are possible with 8-MHz Doppler tone assessment for identifying neurovascular bundles [11].
- Doppler imaging is a promising improvement over handheld Doppler assessment but higher resolution imaging technology is needed [11].
- MR assessment of Dupuytren’s disease is hindered by the resolution of current equipment, orientation issues due to multiplanar deformities of the fingers, and lack of intraoperative availability [11].
- MRI is probably most useful in identifying additional pathology such as flexor tendon bowstringing [11].
- MRI may be helpful in providing a quantitative noninvasive measure of cellularity of affected areas, which is an index of biologic activity [11].
- The potential staging tool of MRI for measuring cellularity has not been investigated yet on a large scale [11].
References
[1] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Evaluation, Clinical Examination, and Imaging > Evaluation and Clinical Examination: Current Concepts.
[2] Exam Of The Hand Wrist 2Ed. INTRODUCTION.
[3] Exam Of The Hand Wrist 2Ed. Functional cutaneous units.
[8] Exam Of The Hand Wrist 2Ed. Techniques of investigation of the arterial supply by J P Melki > Vascularization of the thumb > Palmar aspect.
[11] Dupuytren S Disease And Related Hyperproliferative Disorders. 54. The Future of Dupuytren’s Research and Treatment > 54.4 Mechanical Measurements and Procedures > 54.4.4 Imaging.
