Ingrowing toe nail

What is an ingrowing toe nail

The lateral nail plate pierces the lateral nail fold and enters the dermis

            Causes erythema, granulation tissue and discomfort

What are the causes

• Often multifactorial

Pressure on toe from shoe wearing especially with tight toe

nail fold pushed into the sharp edge of an improperly cut nail, breaking the skin

Bacterial / fungal infection - abscess

Inflammatory process leading to granulation tissues

                  Granulation tissues epithelializes preventing abscess drainage

Heredity factors: genetically predisposed to inwardly curved nails

Underlying bony pathology causing deformation of the nail

Obesity causing deepening of the nail groove

Antiviral therapy for HIV: Indinavir has also been reported to have an association with increased incidence of ingrown nails.

Prior trauma resulting in an irregularly shaped nail

How is the severity of disease assessed

Divided into the following 3 stages:

(1) minimal pain, mild erythema and no discharge, no granulation tissue

(2) crusting and expressible purulence at the nail fold and nail plate junction; and

(3) chronic infection with protuberant granulation tissue extending over the nail plate.

What is the treatment

Depends on stage of disease and patient factors

stage 1 - Mild disease. No granulation tissue no pus

• Proper trimming of the nail at right angles to the distal edge of the nail plate

• the goal being a squared nail with corners protruding distal to the hyponychium

• Wear shoes with a wide toe box or open shoes

• Stage 2 - For disease with purulence but no granulation tissue

• A cotton wedge is placed underneath the nail plate to separate it from the lateral nail fold to relieve the pressure and allow abscess drainage.

• For gross severe sepsis, avulsion of nail under LA allows drainage of abscess and resolution of acute inflammation

• TDS soaking of foot in warm water.

• Culture pus and treat with Abx

• Once swelling decreases, treat as for Stage 1

Stage 3 - chronic infection with protuberant granulation tissue extending over the nail plate.

Surgical treatment is generally preferred

What are the surgical options

Total ablation of the nail – Zadic’s operation. More suitable for older patient with ingrowing toe nails on medial and lateral sides of toe. Older patient where cosmesis is less important.

Wedge Excision of Nail and matrix +/- phenol ablation. More suitable for younger patient where cosmesis is important.

Must exclude peripheral vascular disease by palpating pulses and using ABPI if suspicious.

What is the important anatomy of the nail

 

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i) nail root (germinal matrix): stratum basale and spinosum of epidermis are present here forming nail matrix cells which synthesize the nail plate
ii) nail bed (sterile matrix): stratum spinosum of nail, does not contribute to nail synthesis
iii) nail plate (body): closely compacted, keratin enriched with hard interfibrillar material, it is the stratum corneum of the nail
iv) eponychium (cuticle): junction between skin stratum corneum and base of nail plate
v) hyponychium: junction between the skin stratum corneum and the tip of the nail plate
vi) lunula: light or white region at the base (eponychium) of nail plate

vi) Paronychium – lateral nail fold

Nail Growth

i) keratinocytes in the nail bed (matrix cells) proliferate, grow, synthesize hard keratin, dye, and form the matrix of the nail
ii) lunula is thought to represent immature hard keratin of the developing nail and is an indicator of nail growth
iii) growth is usually fastest in the longest digit

How do you perform wedge excision of the toe nail

• In an appropriately consented and prepared patient.

• The side of the procedure and side of nail is marked in anesthetic bay.

• GA for children. LA for co-operative adults

Prepare the entire foot with Betadine. Free drape the foot to ankle.

 I perform a digital block with 2% lignocaine without adrenaline for local anaesthetic procedures and 0.5 Marcaine for GA. The LA is infiltrates 3-4ml on each side of first digital web space. I also infiltrate some  LA across the dorsum of toe.

• I use penrose drain as a tourniquet wrapped twice around the proximal phalanx and secured with a haemostat for avascular field.

• I sit at the foot of the bed and ask my assistant to flex the digit.

• I make an incision through the nail plate from the eponichium distally to hyponichium. The incision removes ¼ to 1/5 of the width of nail.

• I make a second incision to encompass any granulation tissue outside of the paronychium taking care to not divide the digital nerves laterally.

 Both incisions are carried down to the bone of distal phalynx

• I use a haemostat to gently remove the nail plate of the wedge

 I make radial incision extending from the junction of eponychium and paronychium.

 I ask my assistant to elevate the skin either side of this incision to expose the proximal extent of the germinal matrix.

• I incise and excise this white germinal matrix down to the bone as far as the interphalangeal joint taking care not to transgress the joint capsule.

• I then remove the wedge of lateral nail tissue

 I ensure that all germinal matrix laterally and proximally is seen and removed.

 I use a curette to scrape any remaining tissue from the bone.  

• I close the skin onto the remaining nail using steristrips (not circumferential) distally

• I close the skin of the proximal incision with 2/0 Nylon

• I apply paraffin gauze, telfor and ¼ inch ribbon bandage to toe ensuring that the distal tip of the phalynx is visible.

• I remove the tourniquet and apply direct digital compression for 3 mintes.

• I inspect the tip of the toe to ensure that it remains pink with brisk capillary refill

 

 

 

 

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What are your post operative instructions

• Leave dressings intact for 48 hours shower with bag on foot.

• Keep foot elevated when not walking

• Review in 48 hours and remove dressings and inspect wound

• Wear open toed shoes thereafter

• Remove sutures at 10 days.

What are the important complications

}  Early

§  Ischaemia of toe – ensure tourniquet is removed

§  Bleeding – apply direct pressure. If soaks dressings take back to operating room for exploration

§  Infection – Treat with broad spectrum antibiotics. Open wound to drain sepsis. Regular bathing

}  Late

§  Recurrence of nail spicule

§  Recurrence of ingrown toe nail

How do you perform Zadic’s operation

• In an appropriately consented and prepared patient.

• The side of the procedure is marked in anesthetic bay.

• GA for children. LA for co-operative adults

Prepare the entire foot with Betadine. Free drape the foot to ankle.

 I pperform a digital block with 2% lignocaine without adrenaline for local anaesthetic procedures and 0.5 Marcaine for GA. The LA is infiltrates 3-4ml on each side of first digital web space. I also infiltrate some  LA across the dorsum of toe.

• I use penrose drain as a tourniquet wrapped twice around the proximal phalanx and secured with a haemostat for avascular field.

• I sit at the foot of the bed and ask my assistant to flex the digit.

• Using a haemstat and a Macdonald dissector I elevate the nail plate from the nail bed and avulse the nail.

• I make an H-shaped incision parallel to the eponychium  and extending distally and proximally at the margins at right angles to emcompass the area of germinal matrix.

• I incise just distal to the Lanula to remove the germinal matrix distally

• I use skin hooks to elevate the skin flaps to expose the germinal matrix proximally and I excise the germinal matrix down to the periosteum including as far proximally as IPJ exposing the extensor pollicis tendon.

• I remove the wedge of germinal matrix and I curette away any remaining tissue.

• I close the skin flaps using two loose 3/0 nylon sutures.

• Dressing as for wedge excsion

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