II. Preparation
- Prepare site
- Immerse digit in warm soapy water for 10-15 minutes
- Prepare area with Betadine or hibbiclens
- Digital Block Anesthesia
- Consider Tourniquet (brief application only)
- Apply penrose drain or Rubber band at base of digit
- Reduces bleeding during procedure
- Drape area
III. Technique: Toenail Removal
- Check for adequate Anesthesia
- Elevate nail from nail bed
- Use nail elevator (periosteal elevator)
- Alternative instruments
- Closed tip of iris scissors
- English nail anvil
- Insert under cuticle and nail fold
- Identify line to cut nail
- Partial Nail Avulsion
- Lateral 1/4 of nail (where nail curves down)
- Offers similar outcomes to complete nail excision
- Complete Nail Avulsion: Midline of nail
- Partial Nail Avulsion
- Use nail splitter of sterile bandage scissors
- Cut nail to proximal nail fold
- Grasp nail with hemostat
- Twist lateral fragment outward to remove
IV. Technique: Phenolization for matricectomy (Chemical nail ablation)
- Background
- Chemically destroy nail matrix
- Indications
- Indicated for recurrent Ingrown Nail
- Efficacy
- Phenolization is at least as effective as surgical method
- Gerritsma-Bleeker (2002) Arch Surg 137(3): 320-5 [PubMed]
- Adverse Effects
- Minor increased risk of infection with phenolization (prophylactic Antibiotics not recommended)
- Contraindications
- Do not use phenol in the presence of a pregnant patient or pregnant medical staff
- Peripheral Vascular Disease (relative contraindication)
- Uncontrolled Diabetes Mellitus (relative contraindication)
- Technique
- Phenolization uses phenol 80-88%
- Apply Phenol with cotton swab to matrix for 30 seconds each, and repeat 3 times
- Thoroughly rinse with 70% Isopropyl Alcohol or saline to wash away residual phenol
- Only apply phenol to nail matrix and not to nail bed or surrounding tissue
- Thoroughly cleanse with Isopropyl Alcohol 70% (neutralizes phenol)
V. Technique: Surgical Matrixectomy (nail ablation)
- See Phenolization above for indications
- Laser Method
- Electrosurgical method (Ellman Surgitron)
- Antenna lead placed beneath heel of foot
- Clean surgical field of any blood
- Flat matricectomy electrode (coated on one side)
- Place under nail fold (teflon side facing up)
- Apply cautery to each exposed area
- Set current to 2 (20 W) of coagulation
- Apply current for 5 seconds
- Allow to cool for 15 seconds
- Repeat application of 5 seconds of current
VI. Technique: Dressing
- Apply Vaseline Gauze and tube pressure dressing
- Previously Antibiotic ointment (e.g. Bacitracin) was recommended as part of initial dressing
VII. Management: Home Instructions
- Keep foot elevated for first 24 hours
- Change dressing in 24 hours
- Topical preparations
- No topical agents have been shown to reduce infection or pain, or improve healing
- Tried preparations include Topical Antibiotics, antiseptic, manuka honey and paraffin preparations
- No topical agents have been shown to reduce infection or pain, or improve healing
-
Antibiotics
- Localized inflammation or infection typically resolves after nail removal without Antibiotics
- Oral or Topical Antibiotics are not indicated unless there is clear and widespread associated Cellulitis
- Previously, daily Antibiotic ointment (e.g. Bacitracin) was applied until healed
- Instead, apply Vaseline Gauze and clear bandage to area daily for 1-3 weeks
- Water exposure is controversial
- Some recommend only showering, but no soakings
- Others soak foot in warm soapy water 2-4 times daily for 4-7 days
- Avoid Trauma to toe for first 2 weeks
- Wear loose-fitting shoes
- Avoid Running, jumping or other potential injury
- Observe for signs of infection (Paronychia)
VIII. References
- Mandracchia (July, 1998) Hospital Medicine, p. 36-43
- Peggs in Pfenninger (1994) Procedures, Mosby, p. 28-43
- Heidelbaugh (2009) Am Fam Physician 79(4): 303-12 [PubMed]
- Mayeaux (2019) Am Fam Physician 100(3): 158-64 [PubMed]
- Zuber (2002) Am Fam Physician 65(2):2547-58 [PubMed]