Dermatology Book

Bacterial Infections

Hematology and Oncology

Miscellaneous

Nail Disorders

  • Toenail Removal

Sebaceous Gland Disorders

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Toenail RemovalAka: Ingrown Toenail Avulsion

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  1. Preparation
    1. Prepare site
      1. Immerse digit in warm soapy water for 10-15 minutes
      2. Prepare area with betadine or hibbiclens
    2. Digital Block anesthesia
    3. Consider tourniquet (brief application only)
      1. Apply penrose drain or rubber band at base of digit
      2. Reduces bleeding during procedure
    4. Drape area
  2. Toenail Removal
    1. Check for adequate anesthesia
    2. Elevate nail from nail bed
      1. Use nail elevator (periosteal elevator)
      2. Alternative instruments
        1. Closed tip of iris scissors
        2. English nail anvil
      3. Insert under Cuticle and nail fold
    3. Identify line to cut nail
      1. Partial nail avulsion
        1. Lateral 1/4 of nail (where nail curves down)
      2. Complete nail avulsion: Midline of nail
    4. Use nail splitter of sterile bandage scissors
      1. Cut nail to proximal nail fold
    5. Grasp nail with hemostat
      1. Twist lateral fragment outward to remove
  3. Consider Matricectomy (Ablation)
    1. Will irreversibly destroy nail matrix
    2. Indicated for recurrent ingrown nail
    3. Chemical Method (Phenol or Sodium hydroxide)
      1. Apply Phenol with cotton swab to matrix for 1 min
      2. Repeat application three times
      3. Swab with isopropyl Alcohol (neutralizes phenol)
    4. Laser Method
    5. Electrosurgical method (Ellman Surgitron) - preferred
      1. Antenna lead placed beneath heel of foot
      2. Clean surgical field of any blood
      3. Flat matricectomy electrode (coated on one side)
        1. Place under nail fold (teflon side facing up)
      4. Apply cautery to each exposed area
        1. Set current to 2 (20 W) of coagulation
        2. Apply current for 5 seconds
        3. Allow to cool for 15 seconds
        4. Repeat application of 5 seconds of current
  4. Dressing
    1. Apply antibiotic ointment
    2. Apply gauze and tube pressure dressing
  5. Home Instructions
    1. Keep foot elevated for first 24 hours
    2. Change dressing in 24 hours
    3. Consider daily antibiotic ointment until heeled
    4. Water exposure is controversial
      1. Some recommend only showering, but no soakings
      2. Others soak foot in warm water twice daily for 4 days
    5. Avoid trauma to toe for first 2 weeks
      1. Wear loose-fitting shoes
      2. Avoid Running, jumping or other potential injury
    6. Observe for signs of infection (Paronychia)
  6. References
    1. Mandracchia (July, 1998) Hospital Medicine, p. 36-43
    2. Peggs in Pfenninger (1994) Procedures, Mosby, p. 28-43
    3. Zuber (2002) Am Fam Physician 65(2):2547

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