An intake / peds / fast-track chief complaint with an almost certain procedure: ingrown toenail. To state what may be obvious, this occurs when the distal portion of the nail has improperly grown into the lateral nail folds. It causes inflammation, pain, and often a paronychia, too. It can be caused by poorly fitting (tight) shoes, trauma (think metal cleats), trimming nails too short (they then grown in too many directions), hyperhidrosis, or at worst a subungual neoplasm.

This is a primary care problem that is responsive to primary care recommendations first: elevation, warm soaks, etc. When that doesn’t help the problem, it’s time to fix–at least temporarily–the problem.

One technique is the slant-back repair. This is just how it sounds, you’re going to cut the toenail in a slant to remove a triangular portion including the lateral part that is growing into the nail fold (and a few millimeters towards the center of the nail). It’s a few basic steps:

  1. Explain what you’re going to do, and get consent (verbal is probably fine, but you’re going to be taking instruments to the patient and affecting their not-so-perfect pedicured toes for the summer flip-flop season, so make sure they understand).
  2. Clean the whole area (betadine, chloraprep–your choice).
  3. Digital block the toe roughly the same way you would a finger.
  4. Tourniquet the toe to make this less bloody. You can use a fancy device (try Jenny Sanders’ pockets for one) or a glove tourniquet the same way you would with a finger.
  5. Test that you got good anesthesia with your digital block.
  6. Insert a hemostat to help elevate the nail from the nail bed immediately adjacent to the hypertrophied soft tissue in the nail fold. (Note that this is not 100% necessary, it just helps. If you’re having trouble, skip this step.)
  7. Use small scissors to cut proximally all the way to the nail matrix.
  8. Use the hemostat to remove the free portion of the nail. (Don’t leave any nail in the nail fold or matrix.)
  9. Apply bacitracin, wrap the toe, recommend hard sole shoes (nothing tight) for comfort.

For follow-up, refer to podiatry or primary care for potential ablation of the nail matrix in that area (typically using phenol or electrocautery). AAFP (a great resource for fast-track style complaints) has some good pictures if you’re having a hard time visualizing the cuts. Simple procedure, but better once you’ve done one-or-two.

May 2024