Toes, Ears, FB

Things to consider for foreign body extraction (2)

- If absorbent material, do not irrigate - Live insects: use immersion oil or *lidocaine* (kills insect and provides analgesia)

Complications of ingrown toenail treatment: (2)

- Infection (tx with abx and warm soaks) - Re-growth of nail and return of symptoms

Contraindications to treatment of ingrown toenail: (2)

- Blood dyscrasia - Allergy to local anesthesia (use conservative tx first)

Causes of ingrown toenails (4)

- Cutting nails too short/ not straight across - Unusually curved toenails - Shoes that crowd toenails - Injury

How to anesthetize for subungal hematoma drainage (2)

- Electrocautery: does not need anesthesia, because it is more painful than the actual procedure - Scalpel/18 g needle: digital block

Complications of subungal hematoma drainage (5)

- Injury to nail bed if the tool is advanced too deep - Ineffective drainage - Permanent nail deformity - Functional deficits (numbness) - Infection

What causes subungal hematoma: (2)

- Injury to nailbed (either trauma or tight-fitting shoe) - Bleeding into space between the nail bed and fingernail

Contraindications to subungal hematoma drainage: (5)

- Not painful - Suspected subungual melanoma - Artificial acrylic nails - Crushed or fx nails - Fx of the distal phalanx that results in disrupted nail edges

What are indications for ingrown toenail treatment?

- Onychocryptosis (ingrown nail) - Onychomycosis (fungal infection of the nail) - Chronic, recurrent paronychia (inflammation of nail fold) - Onychogryposis (deformed curved nail)

How do ingrown toenails present? (4)

- Pain along the margin of the toenail that is aggravated by any type of pressure. - Erythema - Swelling - Pustular drainage (if the infection is present)

When should you refer FB in ear to ENT? (6)

- Spherical/sharp objects - Objects touching TM - Objects in ear canal 24hrs+ - Trauma to ear canal (bleeding, limited visibility) - 2+ attempts

complications of FB or cerumen removal from ear: (3)

- TM perforation, ossicle damage, abrasion of canal - Movement of FB further into the canal - Temporary vertigo/ tinnitus

Prior to draining subungal hematoma, you should: (3)

1) Ask PT if they have artificial nails 2) Document size of the hematoma 3) Assess for fx

Cerumen extraction (8 steps)

1) Confirm its actually cerumen 2) Place a waterproof barrier across PTs neck and shoulder on side of the affected ear with the patient sitting upright 3) Fill a large syringe (esp iv catheter tip w needle removed) with body temp water (warm) 4) Have PT or an assistant hold the basin under the ear 5) Please syringe tip or catheter tubing into the canal 6) Irrigate, getting fluid behind impaction 7) Inspect the canal frequently for injury or rupture, repeat as needed 8) Curette may be needed as well

How to prep patient before ingrown toenail removal (3)

1) Explain the procedure 2) Reassure the patient that it will not be painful after the initial injection 3) Indicate the need for the patient to keep their foot still

How to treat the early stages of an ingrown nail??? (4)

1) Frequent soaks in warm water 2) Wear loose-fitting shoes 3) Selective trimming of the nail 4) Cotton under the nail

How to put cotton under the nail in an ingrown toenail: (3)

1) Gently dislodge the lateral edge of the nail plate from the inflamed nail fold 2) Elevate nail plate w/a small cotton wick 3) Place sterile non-absorbent gauze or cotton under the corner of the nail **separates nail from overlying skin so a nail can grow above the skin edge**

How to maintain treatment after putting cotton under ingrown toenail (3)

1) Give the patient a cutout shoe 2) Instructions on replacing gauze daily and performing warm soaks several times a day 3) Educate the patient on the proper trimming of nails w/ squared corners

What to do after FB removed:

1) Re-inspect the canal (look for TM damage) - Ruptured canal: ENT f/u - Wet canal: use isopropyl alcohol or warm blow dryer

Indications for cerumen and FB removal from ear (3)

1) Symptomatic patient (decreased hearing or otalgia) 2) Preventing from the need for visualization 3) Anytime a foreign body is present within the canal

Contraindications for FB or cerumen removal from ear in ER: (4)

1) Uncooperative patient 2) Suspected TM rupture 3) Inability to visualize TM when rupture is suspected 4) Contact of FB with TM

After anesthesia, how do you remove an ingrown toenail? (complete removal, 4 steps)

1. Apply a tourniquet (rubber band) to the base of the toe 2. Cut the nail in half in a lengthwise fashion 3. Loosen and lift the nail with a narrow periosteal elevator/curved needle driver or the flat edge of scissors 4. Gradually separate the nail from the underlying nail bed using gentle upward pressure. (try to minimize trauma to the nail bed)

After anesthesia, how do you remove an ingrown toenail? (partial, 2 steps)

1. Apply a tourniquet (rubber band) to the base of the toe 2. Partial: cut the nail lengthwise with sterile scissors 4-5mm from the affected nail fold

How to ablate nail bed: (4 steps)

1. Dry nail bed w/ sterile gauze 2. Apply 88% phenol solution to the nail matrix w/a sterile cotton-tipped applicator for 3 minutes (do not expose surrounding tissue to phenol solution!) 3. Remove the tourniquet 4. Apply abx ointment with a gauze pad and bulky dressing.

How to administer anesthesia on great toe (7 steps)

1. Place patient supine 2. Scrub with iodine and drape the toe in a sterile fashion 3. Withdraw 5mL of lido w/o epi into syringe 4. First puncture is made dorsomedial at the MTP joint 5. Needle is inserted in a dorso-plantar direction almost to the plantar surface, aspirate 6. Advance the needle toward the plantar side without piercing the volar skin, then slowly inject the anesthetic as the needle is withdrawn 7. Repeat on the opposite side of the MTP joint

Steps to subungal hematoma drainage

1. Prepare digit with betadine 2. Clean the nail with alcohol (clean alcohol off w/ water if using cauter) 3. Using the tool, make a hole at the base of the nail or the center of the hematoma 4. Apply the tool until pops through the nail (don't go too deep!) 5. Allow the hematoma to drain, squeeze w/the tip of the finger 6. Apply antibacterial ointment (bacitracin) and dress w/ gauze 7. Soak digit in warm, soapy water 2-3 times per day

How long should you wait after anesthetizing the great toe to do the toenail removal?

5-10 minutes

How much nail should be removed in toenail removal?

The portion of nail removed should be sufficient that no nail is in contact with the inflamed nail wall

When should pain be relieved with subungal hematoma after drainage?

almost right away. (if it does not, suspect fx or extensor tendon injury)

What is the purpose of a KATZ extractor?

basically a mini catheter, can get behind the object, inflate, and pull FB out

Onychogryposis

deformed, curved nail

What should you always suspect in toe injuries? And how to rule out

extensor tendon injury (do full strength and ROM exam)

When are alligator forceps used?

for soft, easily grasped items like cotton

Onychomycosis

fungal infection of nail

What is the most frequent cause of ingrown toenails:

improperly trimming the nail. - this leads to impingement, inflammation, and infection in the overlying skin of the nail fold

Where is toenail removal done?

in primary care (however permanent removal is usually done by podiatry)

Onychocryptosis

ingrown nail

When is a magnet used?

metal objects

What to do if permanent removal of nail is desired?

nail matrix of nail bed must be ablated aka Chemical Marticectomy (88% Phenol Solution)

is electrocautery of phenol better for ablation of nail bed?

phenol; electrocautery and lasers can be used, but cause more inflammation and postop pain than phenol

Indication for drainage of subungal hematoma:

presence of painful subungal hematoma with nail edges intact (relieve pressure!)

What is definitive tx of ingrown toenail?

remove part of or all of the nail

When are cup-shaped forceps used?

round material (beads) to prevent movement toward TM

What toe is typically involved in an ingrown toenail?

the great toe

How is super glue on a wooden end of a cotton swab used to remove FB

touch to foreign body and let it dry (difficult with children, they move too much and could attach to patient's skin) **make sure glue does not attach to skin*

When is suction used?

used against object for removal