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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 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.

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.15 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 (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 184-1). As the toenail continues to grow, the spike will irritate the soft tissue causing the end result of chronic inflammation and an infection.

Figure 184-1.

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 (Figure 184-2). 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 conservative therapy, fungal infections of the toenail, and severe pain.

Figure 184-2.

Management of stage I and II ingrown toenails. A. Trimming the lateral nail edge. B. Elevation of the lateral nail edge.

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.

General Supplies

  • Povidone iodine or chlorhexidine solution
  • Sterile drapes
  • Sterile gloves
  • Curved hemostat
  • Freer or another periosteal elevator
  • Cotton
  • Scissors or nail splitter
  • Tourniquet or sterile Penrose drain
  • Curette
  • Topical antibacterial ointment
  • 4 × 4 gauze squares
  • ...

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