Ingrown toenail removal

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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

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

See Also

References