Preparation

• Absorbent pad
• Chlorhexidine (or other approved skin cleanser)
• Local anesthetic (see chapter titled “Local Anesthesia” for full procedure)
• 3-10mL syringe, blunt fill and 27g needles
• Sterile gloves
• Sterile drape
• Tissue nipper
• English nail anvil or nail splitter
• Straight forceps or hemostat
• Iris scissors
• Sterile gauze
• Silver nitrate sticks
• Tourniquet
• Cotton-tipped applicator
• Non-adherent gauze dressing
• Roll gauze

Procedure Steps

Step 1: Position the patient

• Supine or seated with the foot extending to the end of the bed
• Place the plantar aspect of the foot on a stable surface
• Place an absorbent pad under the foot

Step 2: Perform a digital block

See chapter titled “Digital Nerve Block” for full procedure.

Step 3: Cleanse affected area

Reduce the risk of infection by preparing the skin with chlorhexidine solution. Cleanse both the injured area and the injection sites with the chlorhexidine solution. Use a circular motion to loosen and remove bacteria and debris.

An alternative option is to soak the digit in the cleansing solution for 5 minutes. Soaking may be preferred for digits that are inflamed or painful (ingrown nail or paronychia).

Step 4: Apply tourniquet to the base of the great toe

Ensure that tourniquet is removed within 15 minutes to prevent ischemia of the toe.

Step 5: Cut the involved nail wedge

Determine if only the spicule or the entire lateral portion of the nail should be removed.

Removal of the spicule (oblique section removal) may be sufficient when inflammation is limited to the area immediately adjacent to the distal nail wall and minimal granulation tissue has formed.

1. Oblique section removal (spicule only)

a. Cut a large enough portion so that no nail remains in contact with the inflamed nail skin fold Make an oblique cut in the distal 1/3 of the affected nail side using the English nail anvil
b. Use forceps to grasp and remove the cut nail

2. Partial nail removal

a. Mark the lateral quarter to third of the nail on the affected side
b. Gently lift the affected portion of the nail from the nail bed using forceps or hemostat
C. Use the English nail anvil (or Iris scissors if nail anvil not available) to cut the nail along the marked line distal to proximal The English nail anvil should not be used to cut farther than 2/3 of the nail distal to proximal to prevent nail bed damage
d. Use small sharp Iris scissors to cut the remaining 1/3 of the nail to just beneath the cuticle
-the base of the nail extends a few millimeter past the cuticle
e. Grasp the cut nail with forceps or hemostat
f. Rotate the nail away from the lateral edge toward the intact nail while pulling the loose piece from it’s attachment
g. Inspect the area to ensure to nail pieces remain behind
– use the forceps to debride the area of loose nail pieces or hyperkeratotic tissue

Step 6: Debridement of the granulation tissue

• The granulation tissue is present at the lateral nail fold and can sometimes be layered over the nail plate
• Debridement (debulking) of the lateral nail groove is required to allow for healing and growth of healthy tissue
• Apply silver nitrate to the granulation tissue for 2 to 3 minutes
• Alternatively, electrocautery or chemical solutions (ex: phenol) can be used, but chemical solutions should not be used if infection is present

Step 7: Cover exposed nail bed

• Apply a thin layer of antibacterial ointment to the exposed nail bed
• Cover with a small non-adherent dressing
• Wrap the digit securely with rolled gauze; take care not to wrap too tight

Aftercare

• Elevate the extremity for 2-3 hours after the procedure to decrease pain as the anesthetic wears off.
• Continue intermittent elevation of the extremity over the next 48 to 72 hours to reduce pain and swelling.
• Pain relief with ice application and oral analgesics.
• Wear open-toed shoes after initial procedure.
• Saturate the dressing prior to removal to prevent bleeding and discomfort upon removal.
• Soak the digit in warm water 24-48 hours after the procedure.
• Apply antibacterial ointment and cover with a bandage daily for 7-10 days.
• Review common causes of ingrown toenails and prevention measures.
• Review conservative treatment options for future cases of mild ingrown toenails:
  • Relieve the pressure off the toe by placing a piece of dental floss or small piece of a cotton ball under the corner of your toenail.
  • Soak the foot in warm, soapy water or warm salt water for 10-15 minutes 3 to 4 times per day for 1 to 2 weeks or until the inflammation has improved.

Patient Education

Follow-up

• Monitor for signs and symptoms of infection:
  • Persistent or worsening pain 48 hours after the procedure.
  • Increasing redness of the area.
  • Development of a red streak on the toe/foot.
  • Presence of pus.
  • Fever.
• Arrange for a wound check at 48 hours after procedure.

Key Takeaways

• Mild to moderate lesions typically respond to conservative treatment.
• Moderate to severe lesions require removal of the affected nail plate edge.
• Removal of the spicule only may be sufficient when inflammation is limited to the area immediately adjacent to the distal nail wall and minimal granulation tissue has formed.
• The English nail anvil should not be used to cut farther than 2/3 of the nail distal to proximal to prevent nail bed damage.