Page 137 - 2022 Ranger Medic Handbook

Ingrown Toenail
DEFINITION: Ingrown toenail with inflammatory response.
S/Sx: Pain, edema, erythema, and hyperkeratosis at lateral nail fold; pressure over the nail margins increases the pain;
inflammatory or infectious responses are generally localized.
Initial management is prevention. Appropriate nail hygiene is important. Toenails should be cut straight across, and
the corners should not be rounded off. For mild ingrown toenail initial management should be conservative. The use of
topical antibiotics or drainage of paronychia is appropriate if present. Conservative management is initiated with once to
twice daily warm water soaks with mild traction being applied to the ingrown nail area. Elevation of the nail with a cotton
tip applicator, dental floss or other instrument to pry the nail out of the skin is appropriate. If forceps and appropriate
monitoring is available a small piece of gauze or cotton can be placed under the ingrown nail and removed and replaced
daily to allow the nail to grow.
Partial or complete nail removal is typically indicated in chronic inflammation/infection, with severe pain of both medial SECTION 3
and lateral nail folds, especially if the condition has lasted one month or greater.
1. Partial toenail removal: Clean the site with soap, water, and Betadine; Perform a digital block at the base of the toe
using lidocaine 1%; apply constricting band to base of toe; remove the lateral quarter of the nail toward the cuticle
(or whole nail), using a sharp scissors with upward pressure; bluntly dissect the nail from the underlying matrix with
a flat object, elevate the nail and grasp it with a hemostat or forceps, removing the piece; clean the nail grooves to
remove any debris; remove constricting band; control bleeding with direct pressure and dry the underlying nail bed.
2. Apply Mupirocin 2% ointment to exposed nail bed.
3. Dress with a nonadherent dressing and dry bandage.
4. Instruct the patient to wash the area daily.
5. Recheck wound and change dressing daily.
6. Instruct patient to wear less-constricting shoes and to trim their nails straight across. Optimal care is to limit walking
and marching for 3–5 days.
7. Treat per Pain Management Protocol.
8. Systemic antibiotics are typically not needed in these procedures; however, if an infection is suspected (increasing
pain, redness, and swelling), then treat as per Cellulitis Protocol.
DISPOSITION: Evacuation is usually not required if the condition responds to therapy. The nail bed may have serous
drainage for several weeks but will usually heal within 2–4 weeks.
SPECIAL CONSIDERATIONS:
1. Consider toenail removal only if close follow-up is possible.
2. Local anesthetic with epinephrine for a digital block is still controversial although medically acceptable.

2022 RANGER MEDIC HANDBOOK 123