SAMPLE OF CLINICAL TUTORIAL VOL. I – INGROWN TOENAIL

 

Since ingrown toenails are usually prone to infection, they can result in very serious problems, particularly in the diabetic patient. In fact, many diabetic amputations have started as simple ingrown toenails that were neglected. For this reason it is very important to stress to the diabetic patient that they should not attempt to cut their own toe nails. This should be done by a properly trained health care professional.

 

Treatment of Ingrown Toenails

The typical ingrown toenail patient will present to the doctor’s office with swelling and infection on one or both of the nail borders. The treatment plan that we use in our clinics is as follows. First, it is important to give relief to the patient during the first visit. We accomplish this by removing the offending nail spicule and packing the nail groove with antibiotic ointment and cotton.

 

If necessary, we can block the toe utilizing one to one and a half c.c. of 1% plain lidocaine. For the injection we use a 3 c.c. syringe with a 30 gauge 1 inch needle (available from Becton Dickinson & Co.). Here is how we do the block:

 

The great toe is held away from the second toe. The needle is quickly inserted at the base of the toe just medial to the tendon of extensor hallucis longus and  a wheal is raised. The needle is slowly pushed plantarly, injecting a small amount of the anesthetic solution as the tissues are penetrated. One-half c.c. of the anesthetic is used to raise a wheal on the medioplantar aspect of the hallux (Fig. 2A).

 

 The needle is withdrawn all the way and reinserted at the base of the hallux just lateral to the tendon of extensor hallucis longus. A wheal is raised and the needled is slowly pushed to the lateroplantar aspect of the toe where one-half c.c. of the anesthetic is used to raise a wheal (Fig. 2B). The needle is completely withdrawn, the block is complete.

 

 

 

 

 

 

 

 


Figure 2A. The needle is quickly inserted                             Figure 2B. Next a wheal is raised on the                                                                                           

at the base of the toe medial to the tendon                            lateral aspect of the toe and the needle is

of extensor hallucis longus. One-half  c.c. of                         slowly pushed to the lateroplantar aspect

the anesthetic is used to raise a wheal  on the                       of the toe where one-half c.c. of the

medioplantar aspect of the toe.                                              anesthetic is deposited.   

 

 

If the infection is bad enough, an oral antibiotic drug will be prescribed. During the first visit it is important to tell the patient that ingrown toenails are essentially a surgical problem and that if their condition does not improve they will need surgical correction.

 

 

Surgical Correction

Before we can discus any surgery for the correction of ingrown toenails we must first talk about the importance of the nail matrix and its anatomical location.

 

The Nail Matrix

The nail matrix is the germinating epithelium that forms the nail plate. It is microscopic in size and hard to visualize during surgery. Through clinical experience we have learned that unless the offending portion of the nail matrix is removed, recurrence of horny-like portions of nail is unavoidable.

 

Since the success or failure of any nail surgery operation depends on the complete removal of the portion of offending nail matrix, it will behoove us to review the location of the nail matrix as well as some of the surrounding anatomy.

 

Cadaveric Dissection

A sagittal section of the left great toe was obtained from a well preserved cadaver (Fig. 3A-B, 4A-B). This longitudinal section upon careful examination revealed that:

 

  1. There is a definite attachment, or rather intimacy between the nail matrix, the phalanx, and the periosteum. This area of intimacy seems to fall at the base of the phalanx, specifically at the point where the phalanx slopes superiorly and proximally.

 

  1. The summit of the phalangeal slope flattens out into a mesa, and runs proximally a few millimeters and becomes continuous with the articulating surface of the phalanx. On the mesa there is a groove running from medial to lateral which serves for the attachment of the extensor hallucis longus (Fig.3A-B, 4A-B, and 5).

 

 

 

                                                                                                          Nail              Capsular    E.H.L.

                                                                                                          plate            ligament                                                                         

                                                                                                                                F.H.L.     Capsular

                                                                                                                                                  Ligament

Figure 3A.  Note that nail descends down to the                       Figure 3B. Anatomical structures seen

periosteum at the base of the phalanx.                                       in figure 3A.