Ingrown toenails are a common presenting complaint in my jail medical clinics, just as they were when I worked in the ER back-in-the-day. Of course, not all toe infections are due to an ingrown toenail (which I will talk about later), but when an ingrown toenail is present, removal of the ingrown nail spicula is instantly curative. And unless you remove the ingrown toenail, the toe usually will just smolder along and not get better. So knowing how to properly remove a toenail is a great and useful thing.
However, I have heard that some Correctional Practitioners are unfamiliar and uncomfortable with the procedure of toenail removal and so when faced with a nail that needs to come off, they instead: 1. Leave the nail on to fester, 2. Over-prescribe unnecessary antibiotics, or 3. Send correctional patients to a foot surgeon to have this simple procedure done. All of these are poor medical practice, in my opinion.
Like abscess I&D that I have written about previously, toenail removal seems to be a daunting procedure, but actually is quite simple. Of course, any medical procedure can be done incorrectly or inefficiently. Today’s JailMedicine post is a tutorial on how to cure ingrown nails by performing a simple toenail removal.
You can’t help but notice that the lateral edge of the nail is inflamed and exuding pus, which is then crusting. Of course, not all infections at the edge of a toenail are due to an ingrown toenail. If this were a fingernail rather than a toenail, we would just call the infection a paronychium and not think of the nail being ingrown at all. Toenails can get paronychia as well without being ingrown. However, I was suspicious that this patient indeed had an ingrown nail spicula because the toe problem had been smoldering for so long and also just because it just kind of looked that way. Also, the patient had already tried all of the more conservative therapies, like hot soaks, that sometimes help. So after talking it over with the patient, I removed this toenail.
The procedure of toenail removal consists of these steps:
1. Get consent. This procedure has a low complication rate, but it is not zero! Besides, patients need to know that the new nail will not grow out for many months, sometimes even up to a year. If you don’t tell them this fact up front, they are going to complain–trust me on this.
2. Skin prep. The most important area to prep is not the nail or infected area but rather the base of the toe where I am going to inject the anesthetic. I wiped the entire toe down three times with betadine swabs and then laid out the drapes from a standard suture tray.
3. Anesthetic agent. I always prefer to use 0.25% bupivacaine (Marcaine) rather than lidocaine. Bupivacaine is simply the superior local anesthetic agent. It costs about the same and lasts much longer (12-24 hours instead of 2-4 hours). I don’t think my jails even stock lidocaine anymore. I was taught long ago that the only drawback of bupivacaine was a slower onset of effect than lidocaine. However, after 20+ years of using bupivicaine, I do not think that this is true—or if it is, the difference is not clinically significant. Bupivacaine is quick enough!
Since I was doing a digital block, I did not use epinephrine (though there is a substantial amount of emergency medicine and plastic surgery literature that says that the prohibition against using epinephrine on digits is a myth. If you are interested in this topic, here is a good link).
4. Digital block. I have found that digital blocks work much better for this procedure than does local injection of bupivacaine. If you have not yet learned how to do a digital block, it is well worth the effort. It takes a good 5 minutes at least for a digital block to anesthetize the whole toe, so I use this time to do my initial charting and to set up everything I will need for the rest of the procedure.
5. Detach the adherent nail folds. The nail fold at the base of the nail is also called the eponychium or simply the cuticle. The eponychium is often stuck to the nail and can rip when the nail is removed. Manicurists have a special instrument to detach the eponychium from the nail, but I just used the scissors from the suture kit to peel the eponychium back, until I can easily slide the scissor tip beneath.
6. Detach the lateral nail. This is done by sliding the closed scissor beneath the nail and then spreading the tip. The scissor is then withdrawn, closed and the process repeated until the entire lateral nail is free. The biggest mistake that is made at this stage is to damage the delicate nail bed with the scissor tip. This is bad, because when the new nail encounters the damaged area, it will grow abnormally, with dips or waves. You can avoid damaging the nail bed by slightly angling the scissor tip upward so that you are sure that you are scraping the underside of the nail rather than the nail bed.
7. Roll off the nail. The easiest and least traumatic way to remove the rest of the nail is to attach a hemostat (which is conveniently included in a standard suture tray) to the free edge of the nail and roll the nail off exactly like rolling off the top of a can of sardines. I usually take off the whole nail, as I have done here.
Note the nail spiculum that was causing all of the trouble! You can see the normal nail to the left of the hemostat in this picture. Everything to the right is the ingrown nail spiculum. It was a monster!With that huge nail shard poking deep into the soft tissues, this infection never would never have healed without the toenail removal.
Some practitioners prefer to take off only part of the nail. The advantage of this is that the half nail left in place will protect the nail bed from pressure from socks and shoes while it is healing. The disadvantage of this is that it is harder to do than to remove the whole nail. If you are going to take off only the lateral edge of the nail, the time to do this is when you have made the first twist of the forceps, and then you can use your scissors to cut the nail just beneath the forceps. The most common mistake is not taking off enough nail. You should remove 1/3 of the nail at the least.
8. Check for wayward nail fragments. Using your forceps, check beneath the eponychial fold and the lateral nail folds to make sure that you have removed all of the nail. Sometimes, especially when the eponychium is stuck to the nail, the nail can tear and a fragment is left hiding under the eponychium. If that has happened, you don’t want to leave that fragment.
9. Apply a dressing to the freshly exposed nail bed. We used Triple Antibiotic Ointment and a wrap. Wound care thereafter should consist of daily cleaning with soap and water and then redressing.
10. What about nail bed ablation? Podiatrists sometimes cauterize the lateral nail bed in an attempt to prevent the newly growing nail from becoming ingrown again. The first thing to know about this is that not every patient will benefit from nail ablation. Many people (including me, incidentally) will never have a recurrence of one ingrown toenail. Ablation therapy should be reserved for those who have many recurrent episodes of ingrown nails. It is also not a procedure that I do–I think the benefit is too small and the risk too great for most correctional patients.
This entire procedure took only about 15 minutes from start to finish.
Post script. Here is the nail bed three weeks post procedure. You can see the new nail starting to grow nicely. In a few months, it will look like a regular old toenail again! And more importantly, the patient reports that she has no pain in the toe–none. Success!
Mandatory disclaimer: The technique I used here is a result of my Emergency Medicine training, my experience and my preferences. Other practitioners may use other techniques that are just as effective. Some may even disagree with what I have said here! You should develop your own technique based on your training, experience and preferences! A very good official source for the technique of toenail removal is Roberts: Roberts and Hedges’ Clinical Procedures in Emergency Medicine, 6th ed. Chapter 51: Podiatric Procedures. Also, this procedure may not work on patients with fungal infections or who otherwise have deformed or complicated nails.
Do you have a different technique that you use to remove toenails? Please comment!