Emergency Pulse

One of my favorite procedures is removing ingrown toenails.  Usually the patient will present with a swollen, red, and painful lateral toe.  Sometimes the patient will have an ingrown toenail on both sides of the toe.  What are the risk factors associated with developing this painful condition?  According to the folks at MayoClinic.com, the following can cause an ingrown toenail:

• Wearing shoes that crowd your toenails
• Cutting your toenails too short
• Not cutting your toenails straight across
• Unusually curved toenails
• Thickening of the toenails

Usually by the time the emergency room will see these patients, their toe will be very swollen, red, and draining pus.  They also have a funky odor (mmmmm, toejam).  Yuck!  Anyway, conservative treatment of  a mildly ingrown toenail can be warm water soaks, anti-inflammatories, +/- antibiotics,  and placing a cotton ball under the corner of your toenail to allow the edge to grow up and out.  Most of the time if the patient presents to the ED, I offer them the surgical treatment, the lateral nail avulsion. 

The lateral nail avulsion is a procedure that will remove the lateral portion of the toenail.  This is the ingrown part.  After doing a digital block ,  I scrub the toe with betadine and place a torniquet around the proximal toe.  After prepping and draping it, I make sure the toe has adequate anesthesia by poking the tip of it with my tissue scissors.  If the patient does not jump, I begin to cut the lateral 1/4 of the nail, starting distally and ending at the proximal nail fold (cuticle).  Then I will grasp this portion of the nail and rotate the hemostats inward and with firm pressure pull back.  Usually the lateral portion of the nail will pull out fairly easily.  It is very important that you get all of ther proximal nail removed or the patient will continue to have discomfort.  Some providers will then kill the nail matrix using phenol or electrocautery ablation.  Next, the toe is cleansed and an antibiotic ointment is applied along with a bulky dressing.  (First make sure you took the torniquet off, duh.)  I send the patients home with a few pain pills, an antibiotic if infected, instruct them to take anti-inflammatories, leave the dressing on 24 hours, and after that, soak the toe in warm soapy water. 

The patients usually will be very grateful that you fixed their toe.  This is a painful condition and one that we as ED providers can provide definitive treatment and get good results.  Follow up appointment with either their primary doctor or a podiatrist is fine.