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An ingrown toenail (onychocryptosis) is a common affliction that can occur in any toe. It most commonly afflicts the great toe, occurring when the lateral edge of the nail plate penetrates the soft tissue of the lateral nail fold. There are three stages of ingrown toenails. Stage I includes erythema, slight edema, and pain when pressure is applied to the lateral nail fold. Stage II includes the stage I findings, drainage, and infection. Stage III is a magnification of the two previous stages with the addition of granulation tissue and lateral nail fold hypertrophy. Most ingrown toenails can be definitively managed in the Emergency Department.

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The toenail usually does not grow into the soft tissue; instead, the soft tissue overgrows and obliterates the nail sulcus in response to external pressure and irritation.1–5 The nail itself is usually normal, although some older patients have incurved nails. The causes of an ingrown toenail are multiple and include trimming the nails too short, using sharp tools to clean the nail gutters, wearing improperly fitted (too tight) shoes, rotated digits, and bony deformities. Improper toenail trimming results in a small nail spike that continues to grow and irritate the soft tissue (Figure 162-1). The end result is a chronic infection.

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Figure 162-1
Graphic Jump Location

An ingrown toenail. Note the nail spicule and the overgrowth of the adjacent soft tissues.

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Warm soaks, oral antistaphylococcal antibiotics, and shoes with an adequate toe box may be curative in mild cases (stages I and II). Elevate and maintain the nail edge above the soft tissues or trim the edge of the nail. More severe cases (stage III) require partial toenail removal. Have a lower threshold for toenail removal in diabetic patients to prevent a more severe infection from forming. Other indications for removal of an ingrown toenail include chronic or recurring ingrown toenails, failure of optimal conservative therapy, fungal infections of the toenail, and severe pain.

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The only relative contraindication to toenail removal is a decreased vascular supply to the toe. Trim the toenail edge if possible and minimize any injury to the adjacent soft tissues. These patients require an evaluation by a Podiatrist and a Vascular Surgeon to minimize future complications.

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General Supplies

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  • Povidone iodine solution
  • Sterile drapes
  • Sterile gloves
  • Curved hemostat
  • Cotton
  • Scissors or nail splitter
  • Tourniquet or sterile Penrose drain
  • Curette
  • Topical antibacterial ointment
  • 4×4 gauze squares
  • Tape, 1 inch wide

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Chemical Matrix Ablation

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  • Cotton-tipped applicators
  • Phenol solution (89%)
  • Isopropyl alcohol (70%)
  • Silver nitrate matchsticks

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Surgical Matrix Excision

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  • #15 scalpel blade on a handle
  • Needle driver
  • 5–0 nylon suture

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Nail Matrix Cauterization

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  • Electrocautery unit, disposable

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