Ingrown Toenail

By Dr Ahmad Hassan
House Officer
Surgical Unit – II
HFH,Rawalpindi
 Definition
 When the Nail Grows into the nailfold
 Causes
 1)Trauma(Constant/Repetitive)
 2)Genetic predisposition
 3)Improper nail trimming
 4)Tight fitting shoes
 5)Fungal infection
 Stages
Stage Description
1 Erethyma,Edema,Pain at Lateral Nail Fold
2 Increased Pain and Discharge from the edge of toenail
3 Hypertrophic granulation tissue on lateral wall
 Management
 Conservative treatment is given in Stage 1 that
includes

 1)Soak the Foot in Hot water

 2)Use Topical/Oral Antibiotics
 Use antibiotics that cover Gram positive organisms in
patients with no comorbids

 If the patient is immunocompromised/Diabetic use

broad spectrum antibiotics
 When is Surgery
the answer!
 If it is stage 2 or Stage 3 or Stage 1 is not resolved
despite conservative measures !
 Types of Nail Removal
 1)Partial Nail Avulsion -Also known as Zadek’s
Procedure

 2)Complete Nail Removal(Nail Avulsion)

 Steps of Surgery
(Partial Nail Removal)
 1)Apply piodine to the effected area
2)Inject local anaesthetic at the base of the toe i-e Ring Block
 3)Apply torniquet to control the blood flow to the finger
 4)Wait for a atleast 2 minutes and make sure patient’s
area that is to be operated is numb
 5)Use nail anvil to cut through some portion of the nail
 6)pull the effected nail using the forceps along with the
nail bed/germinal matrix
 7)Clean the area to reduce obvious bleeding & Apply
pressure on the side of the toenail to express any pus if
present and clean it
8)Once the pus is cleaned use cautery to control bleeding and ablate
the whole area so that the nail
doesnot grow at that place again
 9)Remove the torniquet
 10)Apply piodine soaked gauze & Apply bandage to
the effected area and wrap well
 Steps of Surgery (Complete
Nail Removal)
1)Apply piodine to the effected area
2)Inject local anaesthetic at the base of the toe i-e Ring Block

 3)Apply torniquet to control the blood flow to the finger

 4)Wait for a atleast 2 minutes and make sure patient’s area
that is to be operated is numb
 5)An Artery is inserted between the nail plate and the
nail bed so that one can grip the nail and then a
rotating motion removes the whole nail

In this case the rotating motion will be Anticlockwise and

whole nail will be removed in the process
 6)Clean the area to reduce obvious bleeding & Apply
pressure on the side of the toenail to express any pus if
present and clean it

 7)Remove the torniquet

 8)Apply piodine soaked gauze & Apply bandage to the
effected area and wrap well
 What to do after the surgery
 1)Do not Wear Shoes for 3 days
 2)Prescribe the following Medications
 Antibiotics
 NSAIDs + PPI (so that gastric mucosa isn’t damaged)
 3)Ask the patient to keep foot dry
 4)Change dressing twice a day
 5)Follow-up in OPD after 2 weeks ( 1 week if there is
purulent drainage)
 Complications
 Ischemia(due to excessive anaesthetic use)
 Recurrence or regrowth of nail spicule
 Infection
 Persistent bleeding