May 5, 2011 by dailybolusoflr
The lateral portion of the nail can grow and impinge into the soft tissue of the toe. The soft tissues can become swollen, painful and infected.
In these instances, simple removal of the impacted nail is a curative procedure. For patients with severe disease or recurrent disease, they may need referral to podiatry for more definitive care, but you can still perform this simple procedure.
· Perform a digital block and tourniquet the toe (a penrose drain works nicely here)
· The initial goal is the lift the nail off the underlying nail matrix: this can be accomplished using either a specialty instrument called the English nail anvil or general instruments (most ED docs use these). For general instruments, use sharp iris scissors inserted horizontally under the nail and exert pressure in an upward direction while spreading to lift the nail off the underlying tissue but not damage it.
· When the nail is loosened, take a hemostat clamp and insert it underneath the nail. The spicule which sits underneath the lateral skin needs to be removed. This can be accomplished with a firm pulling up of the lateral aspect of the nail with the hemostat. If this is not removed, the procedure will not work.
· With the nail elevated, use the scissors to cut off a sliver of the nail. Do not extend the cut to the eponychium.
· The underlying nail matrix can be treated with silver nitrate if bleeding occurs.
· Apply a topical antibiotic ointment and dress with a non-adherent gauze.
Roberts and Hedges
Linda Regan, MD FACEP
Program Director, Emergency Medicine Residency
Johns Hopkins Medical Institutions