Removal of Ingrown Toenail

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To treat an ingrown toenail, you can either remove the entire nail or just part of the nail on the ingrown side. 

The first step is a digital block. Prep the skin with antiseptic solution. For the great toe, we will do an H-block pattern of injection of local anesthetic. Starting on the medial side, we advance the needle close to the plantar side of the toe. Aspirate, then inject as you slowly withdraw, anesthetizing the entire medial side of the toe. Once numb, introduce the needle on the dorsomedial of the toe and advance it until it’s on the lateral side. Aspirate, then inject as you withdraw, delivering local anesthetic across the entire dorsal side of the toe. Finally, introduce the needle into the anesthetized, dorsolateral side of the toe. Advance until you are at the plantar side of the foot just under the skin. Aspirate, and inject as you withdraw the needle. This should give effective anesthesia of the entire toe.

Apply a tourniquet to the toe to minimize bleeding. Not shown, but if a nail elevator is available, you should use it to separate the nail from the nail bed under the portion of the nail you plan to remove. Use scissors to cut literally the lateral 1/4 to 1/3 of the toenail all the way to the base. Apply upward pressure as you cut to avoid damaging the nail matrix. Clamp the portion of the nail you plan to remove and rotate it towards the intact piece of nail while applying axial traction. Pull and rotate until the affected portion of the nail is removed all the way to the base. If any remaining nail is left at the base, you should attempt removal.

You can ablate the lateral portion of the nail matrix using silver nitrate or another available product (not shown in video). A non-adherent dressing can be applied to the toe. In this case, we apply antibiotic ointment with 2x2 gauze over the top and dress the toe with a bandage. Alternatively, you may use petroleum-infused gauze on the exposed nail bed.

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ramesh k. -

I place a tourniquet before doing the digital block. It seems to give more dense anesthesia. I usually wait at least 7-10 minutes after injecting to do the procedure. Also I make sure that I separate the nail bed from the nail before inserting a scissors so as not to damage the nail bed. I also give some tylenol and/or ibuprofen before sending them home. I've had some EPs not want to touch a diabetic with an ingrown toenail which I think is unnecessary. In these cases you may want to have them return in 2-3 days for a wound check. I do not use prophylactic antibiotics in these instances.

John F. -

Thanks for the video!
I prefer using the method in which the wedge of skin that the nail is digging into is removed, instead of the nail.
The nail is left intact and is not touched.
Works great, and the ingrown toenail never recurs. Try it sometime!
Sincerely, John Fowler, MD

Joel P. -

A plastic surgeon watched me do this and said that you should always "blow slow before you go" to do the block so that there is always lidocaine ahead of the needle to make the block as painless as possible. That, paired with a 10:1 lido with epi:bicarb mix seems to make the digital block basically painless. Using a 27G forces you to slow down to do this with the added benefit of a mear painless first poke. Received great feedback from patients with this technique.

Melissa B. -

What kind of scissors are they using in this video @Jess?

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