Tips for General Practitioners – Ingrowing Toe Nail

Ingrowing Toe Nail

Ingrown toenail or “onychocryptosis” is a commonly encountered problem. It frequently affects teenagers or young people in their twenties. Patients usually complain of pain at the onset but quite frequently infection complicates the problem.

Antibiotics are important to clear infected cases and proper nail care must be emphasized to all patients. Excision of the nail is useful to get rid of the problem but can be frustrating to both patient and physician as recurrence of the ingrowing nail is common.

Wedge excision with ablation of the underlying nail matrix is a very successful technique for treating ingrown toenails. By limiting the excision to the lateral fourth of the nail, more of the nail is preserved and better cosmesis is achieved. Ablation of the lateral nail matrix is the most important part of the procedure. Failure to completely remove the lateral nail matrix will lead to the lateral part of the nail regrowing under the lateral nail fold and hence causing the problem to recur.

 

Equipment

  • Simple dressing set
  • Local anaesthetic
  • Scissors and small scalpel
  • Artery forceps
  • Small curette
  • 2 inch crepe bandage

 

Technique for excision of an ingrowing toe nail

Aseptic techniques should be used and universal precautions should be adhered to.

IGTN

 

Figure 1.

IGTN 2

Figure 2.

Local anesthetic should be infiltrated on both sides of the toe. 2 to 3mls of a 1% Lignocaine solution on either side should be sufficient to provide adequate anaesthesia.

IGTN 3

Figure 3.

After testing to ensure that the anaesthetic as taken effect, a tourniquet is applied to secure a bloodless operating field. A sterile rubber band can be used , alternatively, the cut off fingertip of a sterile glove as in this picture.

IGTN 4

 

Figure 4.

By using a pair of scissors or a scalpel, a wedge excision of the outer one fourth of the nail plate can be done. This excision should be continued from the tip of the nail down to the nail fold.

IGTN 5

 

Figure 5.

The nail plate is then securely gripped and avulsed with a simple twisting motion. If avulsion is incomplete, care must be taken to regrasp and completely remove the remaining nail plate under the nail fold.

IGTN 6

 

Figure 6.

Care should be taken to excise the nail bed and ablate the nail matrix by using a small curette. Adequate analgesia is important to ensure patient comfort at this stage.

IGTN 7

 

Figure 7.

Be sure to remove the tourniquet!!

IGTN 8

 

Figure 8.

A nice firm bandage is applied taking care not to compromise the circulation.

 

Post op advice for patients

  • Patients should be instructed to elevate their limbs for 24 hours.
  • Bleeding and soaking of the bandages is invariable and this should be explained to the patient.
  • A review should be organised for the next day to change and lighten the dressings.

 

Contraindications

Patients with diabetes and compromised circulation.