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INTRODUCTION

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.1 Stage I includes erythema, slight edema, and pain when pressure is applied to the lateral nail fold. Stage II includes the stage I findings plus signs of infection and a purulent drainage. Stage III is a magnification of the two previous stages with the addition of granulation tissue formation and lateral nail fold hypertrophy. Most ingrown toenails can be definitively managed in the Emergency Department by the Emergency Physician.

ANATOMY AND PATHOPHYSIOLOGY

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.2-6 The toenail itself is usually normal, although some older patients may have incurved nails. The causes of an ingrown toenail are multiple and include trimming the toenails too short, using sharp tools to clean the toenail gutters, wearing improperly fitted (i.e., too tight) shoes, rotated digits, and bony deformities. Improper toenail trimming can result in a small nail spike on the lateral aspect of the toenail (Figure 218-1). As the toenail continues to grow, the spike will irritate the soft tissue causing the end result of chronic inflammation and an infection.

FIGURE 218-1.

An ingrown toenail. A. Photograph. (Used with permission from Sherman S: Simon’s Emergency Orthopedics, 7th ed. New York: McGraw-Hill; 2015.) B. Artist drawing noting the nail spicule and the overgrowth of the adjacent soft tissues.

INDICATIONS

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 (Figure 218-2). More severe cases (stage III) require partial toenail removal. For those with incurved toenails or abnormally wide toenails, partial nail avulsion and phenol treatment are usually indicated as simply instructing on proper toenail cutting is not sufficient.7 When caused by nail spikes from improper nail trimming, usually in younger populations, these infrequently require partial nail removal and can be treated conservatively with instruction on proper nail trimming and proper fitting shoes. 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 conservative therapy, fungal infections of the toenail, and severe pain.

FIGURE 218-2.

Management of stage I and II ingrown toenails. ...

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