Onychocryptosis Ingrown Toenail

Ingrown toenails occur when a segment of the nail plate penetrates the nail sulcus and subcutaneous tissue. Curvature of the nail plate is the most common predisposing factor. The lesion usually occurs as a result of external trauma or self-treatment. Onychocryptosis is characterized by inflammation, swelling, and infection of the medial or lateral aspect of the toenail. The great toe is the most commonly affected. Protracted infection may result in periungual ulcerative granulation. In patients with underlying diabetes or arterial insufficiency, cellulitis, ulceration, and necrosis may lead to amputation if treatment is delayed. If infection is not present at the time of presentation, simple elevation of the nail with placement of a wisp of cotton between the nail plate and the skin, daily foot soaks, and avoidance of pressure on the nail is usually sufficient treatment. Another option, if no infection is present, is to remove a small spicule of the offending nail. A digital block is placed as described below. The area is cleaned, and the skin is prepared for surgical procedure. An oblique portion of the affected nail is trimmed about one-to two-thirds of the way back to the posterior nail fold. The nail groove should then be debrided, and a nonadherent dressing placed -i20 (Fig 2Z9-1).

If granulation or infection is present, then partial removal of the nail plate is indicated. This is performed by placing a digital block and preparing the area for a surgical procedure. The entire affected area, one-quarter or less of the nail plate, is cut longitudinally (anterior to posterior), including the portion of the nail beneath the cuticle. English anvil scissors or a nail splitter are the optimal instruments for cutting the nail. The affected cut portion of the nail is then grasped with a hemostat and, using a rocking motion, removed from the nail groove. The nail groove is then debrided and a dressing is placed 20 (Fig, 2Z9,-2.).

FIG. 279-2. Partial toenail removal (infection present).

One may also cauterize the exposed nail plate. However, cauterization should only be performed by those with appropriate experience with this procedure. 20 An 88% phenol mixture can be applied for 30 s with a cotton-tipped applicator. The phenol is then rinsed with an alcohol solution. Any phenol that comes in contact with healthy tissues must be removed immediately. Silver nitrate also may be used to cauterize the area and should be left on the nail matrix for 1 min. Cauterization is not without risk, as these chemicals may cause extensive tissue destruction. Hemostasis is also extremely important in order to avoid inadvertent absorption of these toxins.

Once the procedure is completed, a nonadherent gauze or antibiotic ointment should be placed on the wound. A bulky dressing should then be placed on the toe. The wound should be checked in 24 to 48 h.20

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