Ingrown Toenails

CHAPTER 29 Ingrown Toenails



Madelyn Pollock


Ingrown toenails usually present with pain, redness, swelling, and sometimes discharge. It is not uncommon for patients to have attempted self-remedies. Often, the irritation is long-standing enough to cause granulation tissue to form. The great toe is virtually the only toe involved, and either the medial or lateral border of the nail may be affected.


Figure 29-1 is an algorithm for the suggested treatment of an ingrown toenail.


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Figure 29-1 Algorithm for a suggested approach to the patient with an ingrown toenail.


(Modified from Heidelbaugh JJ, Lee H: Management of the ingrown toenail. Am Fam Physician 79:303–308, 2009.)


Removal of the toenail, either partial or total, remains the definitive treatment for bothersome ingrown nails. For recurrent episodes, ablation of the germinal matrix tissue can be used to prevent regrowth of the nail. Permanent destruction can be effected using chemicals or radiofrequency energy.



Anatomy


Figure 29-2 illustrates the nail bed anatomy.


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Figure 29-2 Nail bed anatomy and terminology. Also see more details in Chapter 27, Nail Bed Repair.



Indications



• Onychocryptosis (ingrown nail)

• Onychomycosis (fungal infection of the nail) with significant pain; without medical treatment, however, the fungus will recur

• Chronic, recurrent paronychia (inflammation of the nail fold)

• Onychogryposis (deformed, curved nail)

For a first occurrence, it is reasonable to remove only the offending portion of the nail and allow regrowth while educating the patient to correct all offending practices such as overtrimming nails and wearing tight-fitting shoes. If an ingrown nail recurs, permanent ablation of the portion of nail matrix causing the problem is indicated.



Contraindications



• Allergy to local anesthetics (see Chapter 5, Local and Topical Anesthetic Complications).

• Bleeding diathesis.

• Diabetes mellitus and peripheral vascular disease are relative contraindications and should be considered on a case-by-case basis.

• Pregnant patients should not have phenol ablation.


Equipment and Supplies



• 5- or 10-mL syringe with long (image-inch) needle (25 or 27 gauge).

• Local anesthetic generally without epinephrine (e.g., 2% lidocaine with or without sodium bicarbonate buffer to decrease the sting; see Chapter 4, Local Anesthesia). Recent research does not confirm the previous concerns that epinephrine might cause excess vasoconstriction in the digits. However, with patients at high risk, such as those with long-standing diabetes or severe peripheral vascular disease, it might be best to avoid it.

• Narrow Locke periosteal elevator (nail elevator; Fig. 29-3).

• Sterile scissors with straight blades (or an English nail splitter [Fig. 29-4] or miniblade with wedge tip).

• Wide rubber band, small Penrose drain, donut digital tourniquet (Ellman Corp.; Fig. 29-5), or a portable blood pressure cuff (tourniquets are optional but very helpful).

• Two straight hemostats.

• Silver nitrate sticks for cautery of granulation tissue (optional). Best to curette this tissue off with a reusable dermal curette.

• Alcohol swabs.

• Povidone–iodine (Betadine) solution.

• Monsel’s solution to control any possible bleeding after the tourniquet is removed.

• Sterile gauze and tubular gauze dressing.

• Antibiotic ointment (Polysporin or Bacitracin).

• Phenol solution (88%) and isopropyl alcohol for permanent ablation of the nail, if desired.

• As an alternative to phenol, the Ellman Surgitron (radiofrequency unit) with specially designed, Teflon-insulated matrix ablation tips (less inflammation and excellent results; see Chapter 30, Radiofrequency Surgery [Modern Electrosurgery]).


image


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Figure 29-3 Locke periosteal elevator. A, Front view. B, Side view. C, Miniblade with wedge tip.


(Courtesy of John L. Pfenninger, MD, The Medical Procedures Center, PC, Midland, Mich.)



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Figure 29-4 Nail splitter. A, Flat jaw on bottom. B, Beveled jaw on top.


(Courtesy of John L. Pfenninger, MD, The Medical Procedures Center, PC, Midland, Mich.)


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Figure 29-5 The Ellman digital tourniquet.


(Courtesy of John L. Pfenninger, MD, The Medical Procedures Center, PC, Midland, Mich.)



Preprocedure Patient Education and Consent


See the patient education form online at www.expertconsult.com.


A signed consent is not mandatory but the patient must be well informed of the procedures and the intended outcome. A patient education handout that explains the nature of ingrown nails is helpful. Before beginning the procedure, be sure the patient understands that providing anesthesia is uncomfortable, but after that there should be no pain. There is no guarantee that removing the portion of ingrown nail will resolve the problem, but generally it will if the nails are cared for properly afterward. The major benefit to removing the toenail (or a portion of it) is pain relief, with the secondary benefit of allowing the body to heal the inflamed area.



Procedure


note: Nonsterile gloves may be used in this procedure.



Removal of Partial or Full Nail



1 With the patient in the supine position, prepare the toe with Betadine. If the patient has significant discomfort, anesthesia (step 2) can precede this step for patient comfort.

2 Administer a digital block as described in Chapter 8, Peripheral Nerve Blocks and Field Blocks.

3 Apply a tourniquet if desired. Options include the following:
• Use a straight hemostat to firmly secure a wide rubber band or Penrose drain around the base of the toe.

• Apply a blood pressure cuff at the calf so it will not affect the operative field. To use this method, place the cuff around the calf, elevate the foot to about a 45-degree angle at the hip, and, after 1 to 2 minutes of elevation, raise the cuff pressure to above systolic, lock the cuff it so it stays inflated, and then lower the foot to the operative field. Maintain the pressure until the procedure is completed.

• The Ellman donut tourniquets (see Fig. 29-5) are disposable and come in various sizes. After the procedure, simply cut them with scissors to remove them.

4 Identify the portion of the nail to be removed, which is at least 20% to 25% of the nail.

5 When anesthesia is achieved (5 to 10 minutes), loosen and lift the nail to be removed from the nail bed by using the flat, rounded blade of the scissors, a single jaw of a straight hemostat, or a narrow periosteal elevator. The elevator works best to decrease the likelihood of injury to the nail bed (see Fig. 29-3). Introduce and advance the instrument with continued upward pressure against the nail plate and away from the nail bed to minimize injury and bleeding (Fig. 29-6). It is important to completely free the proximal nail at its base under the nail fold to allow removal and to expose the germinal tissue of the nail bed. Push forward gently—the elevator moves easily when under the nail. Resistance will be felt when the proximal end of the nail plate has been loosened sufficiently. Release the entire nail plate in this fashion if the entire nail is to be removed.

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Ingrown Toenails

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