Time to downshift a little bit from the low frequency, high stakes procedures. This is a low stakes, probably low frequency procedure.

This week: TOENAIL REMOVAL – it’s not just for podiatrists. We will focus on the management of an ingrown nail, but the technique for getting under the nail can be used to remove the entire nail (and is included in one of the video references).

The fancy term for this condition is onychocryptosis. It generally occurs most frequently on the large toe but can happen on any of the fingers/toes. Ingrown nails can be caused by abnormal toenail growth and overgrowth of the skin around the nail. Improper nail cutting technique, poor fitting shoes with inadequate room for the toes, damp footwear, genetics/shape of the nail, infection of the nail/paronychia, and trauma to the nail are all causes. You will want to counsel your patients about proper footwear (room for toes) and nail trimming (cut straight across, don’t curve).

Consent Considerations:

Risks:
- Recurrence, abnormal appearance of the nail, infection, bleeding, thickening or discoloration of the nail as it grows back (can be permanent), damage to surrounding structures (nerves, vessels, skin).
- Patients with diabetes or peripheral vascular disease may be higher risk for complications
Alternatives:
- Can splint nail or use gauze to lift the nail, but this can take months to heal as the nail grows out and will require frequent replacement of the splint/gauze
- Use soaks and gently push the side of the nail back, followed by application of a topical antibiotic. This will also take a while to heal but may be a good option for mild-moderate cases.

Preparation:

Supplies for a digital block – lidocaine WITHOUT epi, can use topical spray to help numb skin for lidocaine injection
Digit/ring tourniquet
- Can also take tourniquet used for IVs, penrose drain, rolled up glove and wrap around digit, securing with a hemostat

Another hemostat for lifting and pulling out the edge of the nail once it is cut
A good pair of scissors that can cut through a nail or a designated nail clipper that looks like this:

How to do it:

Digital block
Tourniquet the digit
Clean skin/nail with betadine
Use hemostats to gently blunt dissect under the nail on the side that it is ingrown to raise it up
Use the scissors or clippers to cut in a straight line from the nail edge to the cuticle, perpendicular to the cuticle
- Where you cut depends on how much of the nail is ingrown – you want to remove enough that there is no nail underneath the medial/lateral nail fold

Grab the piece of the nail that you are removing with the hemostat
Twist the piece and remove it – make sure to get out any remaining pieces of nail underneath the nail fold
- Can use a cotton tipped applicator to clean
The cuticle tends to bleed – you may need to apply some pressure prior to removing the tourniquet
Remove tourniquet if no bleeding.
Apply antibiotic ointment and a dressing
Follow up with PCP or podiatry if recurrent or severe

References:

https://www.aafp.org/pubs/afp/issues/2009/0215/p303.html
https://www.aafp.org/pubs/afp/issues/2019/0801/p158.html
https://www.aliem.com/trick-of-trade-toenail-splinting-for/
https://accessemergencymedicine.mhmedical.com/content.aspx?sectionid=45343834&bookid=683
https://wikem.org/wiki/Ingrown_toenail_removal

Videos:

https://www.youtube.com/watch?v=7NesY1pFXRc
- Really quick video
https://www.youtube.com/watch?v=uYcSvHJJm7U
- Includes description of risks/indications and list of all the equipment you will need
- The physician in this video uses phenol (causes destruction of nail matrix to prevent regrowth) – this is likely not something you will do in the ED
https://www.youtube.com/watch?v=4kV_plba6TQ
- Longer video but has some good tips from a podiatrist
https://www.youtube.com/watch?v=YewetTdAQS4
- Shows removal of an entire nail