Ingrown toenail removal: Difference between revisions

Revision as of 16:24, 9 October 2019

Background

Nailtip Anatomy

A. Nail plate; B. lunula; C. root; D. sinus; E. matrix; F. nail bed; G. hyponychium; H. free margin.

The perinychium includes the nail, the nailbed, and the surrounding tissue.
The paronychia is the lateral nail folds
The hyponychium is the palmar surface skin distal to the nail.
The lunula is that white semi-moon shaped proximal portion of the nail.
The sterile matrix is deep to the nail, adheres to it and is distal to the lunule.
The germinal portion is proximal to the matrix and is responsible for nail growth.

Indications

Advanced onychocryptosis (heavy granulation tissue, pain with walking)

Contraindications

Significant granulation tissue precluding partial nail removal
Multiple comorbidities in a patient not requiring immediate relief

Equipment needed

Gloves
Chlorhexidine or betadine
Syringe with 27-ga needle
1% lidocaine without epinephrine or 0.5% bupivacaine
Gauze
Thin flat hemostat
Straight forceps
Iris scissors
Aqueous phenol or silver nitrate

Procedure

Perform Digital block using lidocaine without epinephrine or bupivacaine
Clean area thoroughly

Partial nail removal

Removing the entire outside portion of affected nail (definitive treatment)

Lift the affected side (up to 1/3 of the nail) off of the nail bed via blunt dissection with a hemostat
Grasp the nail fragment with the hemostat and use a rotating motion with the clamped hemostat toward the remaining nail to expose the outside portion of the lunula
- The lateral portion of the lunula looks like a "dolphin's tail"; do not p
Cut the nail with scissors or a nail anvil, distal to proximal, parallel to nail wall, with care not to injure the eponychium

Matricectomy

Ablating the lateral matrix can decrease recurrence

Perform complete lateral nail removal as above
Apply a toe tourniquet for a bloodless field
Clean and dry base thoroughly
Ablate nail matrix by applying 1% aqueous phenol solution or silver nitrate

Post-procedure care

Cover with gauze, instruct to keep clean and dry, wash 2-3 times a day
No antibiotics unless surrounding cellulitis

Complications

Recurrence
Infection
Bleeding
Retained nail fragment

References

Authors:

@@ Line 1: / Line 1: @@
-== Background/Indications ==
+==Background==
-*Lateral nail edge grows deep into nail wall
+{{Fingertip anatomy}}
-*Cycle of inflammation, hypertrophic granulation tissue, can lead to abscess
-*Minor cases can be treated nonsurgically
-*Removal indicated for advanced disease – heavy granulation tissue, pain with walking
-== Contraindications ==
+==Indications==
+*Advanced [[ingrown toenail|onychocryptosis]] (heavy granulation tissue, pain with walking)
+==Contraindications==
 *Significant granulation tissue precluding partial nail removal
 *Multiple comorbidities in a patient not requiring immediate relief
-== Equipment needed ==
+==Equipment needed==
 *Gloves
-*Alcohol swab
+*Chlorhexidine or betadine
-*27-ga needle, syringe
+*Syringe with 27-ga needle
-*1% lidocaine without epinephrine
+*1% lidocaine without epinephrine '''or''' 0.5% bupivacaine
-*0.5% bupivacaine
-*Aqueous phenol or silver nitrate
 *Gauze
 *Thin flat hemostat
 *Straight forceps
 *Iris scissors
+*Aqueous phenol or silver nitrate
-== Procedure ==
+==Procedure==
-*Digital block using 1% lido without epi, consider adding bupivacaine
+*Perform [[Digital block]] using lidocaine without epinephrine or bupivacaine
 *Clean area thoroughly
-=== Partial nail removal ===
+===Partial nail removal===
-#If only the distal nail wall is inflamed, use iris scissors or an English nail anvil to make an oblique cut through the distal one third of the nail
+''Removing the entire outside portion of affected nail (definitive treatment)''
-#Use forceps to help remove the corner
+*Lift the affected side (up to 1/3 of the nail) off of the nail bed via blunt dissection with a hemostat
+*Grasp the nail fragment with the hemostat and use a rotating motion with the clamped hemostat toward the remaining nail to expose the outside portion of the lunula
-=== Complete (lateral) nail removal ===
+**The lateral portion of the lunula looks like a "dolphin's tail"; do not p
-Removing the entire lateral portion of the nail is the more definitive treatment
+*Cut the nail with scissors or a nail anvil, distal to proximal, parallel to nail wall, with care not to injure the eponychium
-#Lift the lateral quarter or third of the nail off of the nail bed with a hemostat
-#Cut the nail with scissors or a nail anvil, distal to proximal, parallel to nail wall, with care not to injure the eponychium
-#Grasp the nail fragment with the hemostat and pull in a twisting motion distally and toward the remaining nail until removed
-#Gently debride the exposed tissue
-=== Matricectomy ===
+===Matricectomy===
-Ablating the lateral matrix can decrease recurrence
+''Ablating the lateral matrix can decrease recurrence''
-#Clean and dry thoroughly
+*Perform complete lateral nail removal as above
-#Apply a toe tourniquet for a bloodless field
+*Apply a toe tourniquet for a bloodless field
-#Ablation of matrix can be done using 1% aqueous phenol solution or silver nitrate, among other techniques
+*Clean and dry base thoroughly
+*Ablate nail matrix by applying 1% aqueous phenol solution or silver nitrate
-=== Post-procedure care ===
+==Post-procedure care==
 *Cover with gauze, instruct to keep clean and dry, wash 2-3 times a day
-*No antibiotics unless cellulitis
+*No antibiotics unless surrounding cellulitis
-== Complications ==
+==Complications==
 *Recurrence
 *Infection
@@ Line 52: / Line 48: @@
 *Retained nail fragment
-== Source ==
+==See Also==
-emedicine
+*[[Ingrown toenail]]
-== See Also ==
+==References==
-*[[Paronychia]]
+<References/>
 [[Category:Procedures]]