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Manage early ingrown toenails (stages I and II) with conservative therapy. Remove the medial or lateral one-quarter of the toenail along with the germinal matrix at the base of the toenail for stage III ingrown toenails. The entire nail may be removed if both sides are ingrown. It may be necessary to prevent any new nail growth in the area once the nail has been removed. Three options include chemical ablation of the matrix, surgical excision of the matrix, and electrocautery of the nail matrix. The treatment of the pediatric patient is no different than the adult patient.
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Toenail Elevation and Trimming
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Ingrown toenails in the first two stages can be trimmed or elevated to relieve the patient's symptoms (Figure 184-2). Trim the distal edge of the nail plate to remove the ingrown portion (Figure 184-2A). Remove the distal one-third to one-half of the nail plate. Smooth the nail plate edge so that it will grow out freely. Remove any debris along the lateral nail fold (paronychia) or nailbed.
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An alternative is to elevate the edge of the nail plate (Figure 184-2B). Insert the jaws of a hemostat so that one is above and the other is below the ingrown nail edge. Clamp the jaws of the hemostat onto the nail plate. Slowly rotate the hemostat to elevate the edge of the nail plate above the adjacent soft tissues (Figure 184-2B). Insert a wad of cotton under the nail edge to maintain it above the adjacent soft tissues. Release the hemostat. Teach the patient and/or their representative this technique so that they can replace the cotton wad daily until the nail plate grows out and past the soft tissues. The main disadvantages of this technique are that the patient or their representative must elevate the nail edge and replace the cotton daily as well as maintain the nail plate elevation for 3 to 6 weeks. This can be quite a challenge, if it is even possible, in the young child.
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Apply a tourniquet along the base of the afflicted toe (Figure 184-3A). The tourniquet may be a commercially available product for the digits or a Penrose drain. Refer to Chapter 104 for several examples of digital tourniquets. Separate the nail from the underlying nail bed. Grasp and stabilize the toe with the nondominant hand. If available, use a Freer periosteal elevator to lift the soft tissue off the lateral and proximal toenail. The elevator can also be used to separate the nail plate from the underlying nail bed, but this is optional. Insert one jaw of a curved hemostat under the distal toenail margin and along the medial or lateral side of the nail plate, depending upon which side is ingrown (Figure 184-3B). Advance the hemostat until the jaw is at the proximal corner of the involved side of the ingrown nail (Figure 184-3C). Grasp the nail by clamping the jaws of the curved hemostat on the toenail.
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Dislodge the ingrown nail from the skin, the nail bed, and the nail matrix by rotating the hemostat away from the ingrown portion (Figure 184-3D). Continue to rotate the hemostat until the entire ingrown portion of the nail is separated from the skin, the nail bed, and the nail matrix. A large and complete portion of the underlying toenail will emerge from under the skin fold (Figure 184-3E). The nail plate might have broken and a significant piece may still be under the inflamed skin border if only a small amount of the nail is visible after rotating the hemostat. Expose this area and use the curved hemostat to remove any remaining nail plate.
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Cut away the ingrown portion of the toenail, from distal to proximal, with a heavy scissors or nail splitter (Figure 184-3F). Make sure that the points of the scissors or nail splitter are facing upward to prevent injury to the nail bed. The granulation tissue overlying the nail bed must be removed to prevent another ingrown toenail (Figure 184-3G). Trim the granulation tissue using a #15 scalpel blade or a curette (Figure 184-3H). Remove the tourniquet and control any bleeding.
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Some Emergency Physicians prefer to perform the above-described procedural steps in a slightly different order. Apply a tourniquet along the base of the afflicted toe. Grasp and stabilize the toe with the nondominant hand. If available, use a Freer periosteal elevator to lift the soft tissue off the lateral and proximal toenail. The elevator can also be used to separate the nail plate from the underlying nail bed, but this is optional. Cut away the ingrown portion of the toenail, from distal to proximal, with a heavy scissors or nail splitter. Make sure that the points of the scissors or nail splitter are facing upward to prevent injury to the nail bed. Insert one jaw of a curved hemostat under the distal toenail margin and along the medial or lateral side of the nail plate, depending upon which side is ingrown. Advance the hemostat until the jaw is at the proximal corner of the involved side of the ingrown nail. Grasp the nail by clamping the jaws of the curved hemostat on the toenail. Dislodge the ingrown nail from the skin, the nail bed, and the nail matrix by rotating the hemostat away from the ingrown portion. Continue to rotate the hemostat until the entire ingrown portion of the nail is separated from the skin, the nail bed, and the nail matrix. A large and complete portion of the underlying toenail will emerge from under the skin fold. The nail plate might have broken and a significant piece may still be under the inflamed skin border if only a small amount of the nail is visible after rotating the hemostat. Expose this area and use the curved hemostat to remove any remaining nail plate. Remove the granulation tissue overlying the nail bed to prevent another ingrown toenail using a #15 scalpel blade or a curette. Remove the tourniquet and control any bleeding.
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Chemical Nail Matrix Ablation
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Chemical ablation of the nail matrix with phenol has several advantages.6,7 The procedure is easy, quick, and simple to perform. No special equipment is required. The use of an incision or electrocautery, and their associated complications, is avoided.
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Chemical ablation of the matrix with phenol is the author's preferred method. Remove any obvious remaining nail matrix and nail bed with a blunt instrument such as a curette. Completely dry the field of any blood and fluid. Dip a cotton-tipped applicator in a phenol solution. Avoid excessive saturation of the swab. Introduce the swab between the roof and the root matrix (i.e., under the eponychium) of the removed nail section (Figure 184-4). Rotate the cotton-tipped applicator slowly for 30 seconds (20 seconds for children) and then remove it. Repeat the phenol application two additional times using a fresh phenol-soaked cotton-tipped applicator. Do not allow the phenol to contact normal skin. Immediately wipe off any phenol that contacts the skin. The phenol will turn the tissue pale or gray. Dip a cotton-tipped applicator in isopropyl alcohol. Swab the area in similar fashion as the phenol swab. The isopropyl alcohol neutralizes the necrotizing effect of the phenol.6–8
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An alternative to phenol is silver nitrate. The preferred technique is a phenol matrixectomy. Silver nitrate may be used if phenol is not available. The main disadvantage of silver nitrate is that it turns the tissues black. Insert the silver nitrate matchstick under the eponychium (Figure 184-4). Roll the matchstick around for 5 to 10 seconds to ablate the matrix.
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Surgical Nail Matrix Ablation
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Surgical excision of the toenail matrix requires more time and experience than chemical ablation.4 This technique is usually reserved for the Podiatrist or the Orthopedic Surgeon. An experienced Emergency Physician can easily perform this technique in the Emergency Department. Expose the nail matrix by retracting the adjacent overlying skin. Make an oblique proximal incision from the proximal corner of the nail if necessary to fully expose the nail matrix in the ingrown area (Figure 184-5A). Make an incision with a #15 scalpel blade to separate the nail matrix to be removed from the remaining nail and matrix (Figure 184-5B). Grasp the corner of the matrix with a hemostat. Use the scalpel blade to separate the matrix from the underlying tissues. Remove the nail matrix. Do not forget to remove the dorsal and deep matrix that envelops the base of the toenail under the skin fold. Remove any remaining nail matrix and nail bed with a curette. Close the skin incision with 5-0 nylon suture.
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Electrocautery Nail Matrix Ablation
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Electrocauterization of the nail matrix is rapidly performed but requires access to an electrocautery instrument. Apply electrocautery between the roof and the root matrix of the removed nail section to destroy the matrix in this area. Avoid excessive burning of the surrounding tissues. This technique can cause significant damage to normal tissue and should be reserved for the Podiatrist or the Orthopedic Surgeon.