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.
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.
An ingrown toenail. Note the nail spicule and the overgrowth
of the adjacent soft tissues.
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.
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.
- Povidone iodine solution
- Sterile drapes
- Sterile gloves
- Curved hemostat
- Scissors or nail splitter
- Tourniquet or sterile Penrose drain
- Topical antibacterial ointment
- 4×4 gauze squares
- Tape, 1 inch wide
- Cotton-tipped applicators
- Phenol solution (89%)
- Isopropyl alcohol (70%)
- Silver nitrate matchsticks
- #15 scalpel blade on a handle
- Needle driver
- 5–0 nylon suture
Nail Matrix Cauterization
- Electrocautery unit, disposable
Explain the risks, benefits, complications, and aftercare of
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