Ingrown toenail
When should patients follow up for an evaluation?
1 week unless concerns of infection
In a partial toe nail removal, what are 5 steps done after the toe nail is actually removed (closing steps)?
1. Examine nail bed for debris or splinters 2. remove tourniquet 3. cauterize matrix (optional) 4. Apply antibiotic ointment to nail bed 5. cover with sterile dressing
What are 5 other causes of an ingrown toe nail?
1. cutting nail at a rounded angle 2. accumulation of debris 3. congenital malformation 4. curling or deformity due to trauma or excessive growth 5. poor fitting shoes
What are the 7 simplified steps for a partial ingrown toenail removal (prep and resection)?
1. prepare sterile field 2. digital block wait 5-20 min 3. add tourniquet around proximal toe (optional) 4. file upper surface of the middle third of the nail until you can see the nail matrix 5. elevate nail with upward pressure and away from nail bed to minimize bleeding and injury 6. grasp the wedge with hemostat 7. In one steady, continuous motion, pull the wedge off with simultaneously twisting toward the affected side of the toe
How does the total nail removal differ from the partial (3)?
1. thin both nail edges (lat and medial) 2. use scissors to cut down the center of the affected nail 3. loosen & remove one side of the nail at a time
How long should a patient wait until they can walk following a ingrown toenail removal? What shoes should they wear?
24 hours open-toed or sandals
When should full healing be achieved from an ingrown toenail removal?
4-6 weeks
How is anesthesia administered with an ingrown toenail resection?
Digital Nerve Block
Which toe most commonly has ingrown toenails? Is the lateral or medial side more commonly affected?
Great toe; lateral side
What is is the medical term for an ingrown toenail?
Onychocryptosis
Which stage is the following ingrown toenail in and how is it managed? tenderness to palpation and with wearing shoes. Erythema and slight swelling at the site
Stage I; warm soaks, cotton wick elevation of affected nail corner, antibiotics if infection
Which stage is the following ingrown toenail in and how is it managed? erythema and tenderness associated with suppuration and a small collection of pus
Stage II; Partial toe nail removal
Which stage is the following ingrown toenail in and how is it managed? pain, redness and heat at the nail edge, lateral nail-fold hypertrophy with granulation tissue, pus collection
Stage III; debride nail groove silver nitrate cautery to hypertrophied nail complete nail avulsion or wedge resection of distal nail edge Electrosurgical matricectomy Surgical excision of nail plate, bed and matrix
Which age group and gender do ingrown toenails commonly affect?
adolescent males
You have a patient appear with purulent discharge around their ingrown toenail. What conditions may occur if treatment is delayed?
cellulitis lymphangitis
What is the underlying cause of inflammation and infection with ingrown toenails?
foreign body reaction to the nail entering the sulcus and subcutaneous tissue
____________ tissue can occur with irritation of an ingrown toenail. What are the problems with this occuring?
hypergranulation; protrudes over nail highly vascular
What are three complications of ingrown toenail removal?
infection excessive bleeding nail regrowth with paronchyia
What are 5 predisposing causes for an ingrown toenail?
involuted toenails shape of nails-- broad at distal edge, large nail plate skin texture toe size onychotillomania (splints nails)
What other condition should be looked for when examining an ingrown toenail?
onychomycosis
What causes periungal tissue to become inflamed with an ingrown toenail?
penetration by the nail spike
What should be included in a vascular status inspection of an ingrown toenail?
pulse temp color ABI
How does the periungal tissue appear with ingrown toenails?
red, hot, swollen and shiny
What are the treatment goals of an ingrown toenail (3)?
removal of nail spike reduce infection if present healing tissue
What are the two short term outcomes in a ingrown toenail removal?
serosanguineous drainage minimal within 24 hours pain well-controlled with non-narcotic analgesia and elevation
What are three indications for nail removal?
trauma onychomycosis ingrown toenail