TEOTWAWKI Medicine and Minor Surgery--Part I: Ingrown Toenails, by Dr. K.

Tuesday, Mar 24, 2009

Introduction

Onychocryptosis (ON-ee-ko-krip-TOE-sis), an ingrown toenail, is a very common problem that usually affects the big toe. This occurs when the corner of the toenail grows into the soft tissue on the side of the toe. This can cause pain, redness, inflammation, and even an infection. Signs of an infection are warmth and drainage of pus. Prevention and treatment of an ingrown toenail is relatively basic, and it is a valuable skill to have at TEOTWAWKI.

Causes
An ingrown toenail is caused when the nail curves down and grows into the skin at the nail border. The most common causes of an ingrown toenail are improperly trimmed toenails and poorly fitting footwear. Other causes include unusually curved toenails, excessive sweating, trauma, fungal infections which cause the nail to grow abnormally, cancers, and even obesity.

Complications
If an infection is left untreated, it can spread into the toe bones. This may lead to amputations, and even death, in rare, worst case scenarios.

Prevention
If you are working outside a lot, which would be most of us in a TEOTWAWKI scenario, then study boots are recommended; consider steel-toed boots if you don’t already have them. Regardless of the footwear you use, make sure that they fit properly! There should not be too much pressure on the top of your toes, and shoes should not pinch your toes together.

Toenails should be kept at a length even with, or just barely shorter than, the tips of your toes. Too long and toenails can break easily or get jammed into the toenail base. Too short and the toenails can be pushed down by your shoes and grow into the soft tissue of the toe. Trim your toenails straight across or with a slight curve. Do not curve your nails to match your toes, and do not trim the outer angles of your toenails. Finally, do not pick, tear, (or bite!) your toenails; only use a toenail clipper and file.

Non-Surgical Treatments – this treats 70%+ of ingrown toenails
* Wear very comfortable shoes; consider wearing sandals until the ingrown nail resolves.
* Soak the foot in warm water 3-5 times a day for 15-20 minutes. Add 1 teaspoon of salt per pint of water.
* Gently push the tissue away from the nail and gently lift the nail up after each soaking.
* Place small, clean tufts of cotton under the edge of the ingrown nail. This relieves some pressure and helps the nail grow above the skin edge.
* Rub a topical antibiotic ointment (such as Neosporin) over the ingrown nail.
* Place a soft bandage over the ingrown nail.
* Keep the foot dry.
* Take some acetaminophen (Tylenol) or ibuprofen (Motrin, Advil, etc.) as directed on the bottle for pain relief.
* If there is no improvement in 2-3 days, then consider the surgical option.

Surgical Treatments: Toenail Removal
Note: If you have had ingrown toenails in the past, there is a good chance you will have ingrown toenails again. If you have had repeated ingrown toenails, consider having your nails surgically treated before TSHTF. A surgical option, regardless of the problem, is always best treated by someone who has been trained to perform the procedure. You don’t want to be patient number one in a survival situation. Finally, while I am explaining how to do this procedure, I only recommend that you attempt this in a post-TEOTWAWKI scenario where there are no other healthcare options. Proceed at your own risk.

The most effective way to treat an ingrown toenail that has not responded to non-surgical treatment is lateral nail avulsion with matricectomy. What does that mean? Let’s break it down. Lateral nail avulsion is digging out and removing one side of the toenail all the way down to the base. Imagine the nail is roughly a square. The ingrown part is on the left side for example. About 1/5 of the nail, the left 1/5, is removed from top to bottom. The remaining 4/5 is left completely intact. Macticectomy is the process of destroying the matrix, or root, of the nail. By removing one side of the nail, the pressure is removed because there is no nail pressing on the tissue any more. This also allows the infection to drain. By destroying the root on that side there is a very slim chance of the toenail growing back in that area. Over time the skin will heal and you will be left with a skinnier toenail that is unlikely to become ingrown again. Now how do you do this?

Supplies
Light (a bright headlamp works well. Consider working outside in the bright sunlight.)
Non-sterile gloves
Sterile gloves
10-mL syringe
27 to 30-gauge needle
Lidocaine 1% or 2%
Povidone-iodine solution (sold as Betadine at most drug stores)
Gauze pads
Drape (sterile sheet)
Iris scissors (small, 3-4 inch long scissors with fine, sharp points)
Bandage scissors if desired (scissors with one side’s outer edge flattened for protection)
Nail splitter if desired (heavy duty scissors with very short, thick blades)
Hemostats (small device that resembles scissors but has clamps instead of blades) a pair of needle nosed pliers (sterilized) can be used in a pinch
Sterile rubber band if desired
Cautery device – read the step-by-step instructions for details
Dressing Materials:
Antibiotic ointment such as Neosporin
Gauze for wrapping the toe
Roll of 1-inch tape

Step-by-Step Instructions
1. Have the patient lie down on a table with their knees bent. Their feet will be flat on the table. Pull up a chair and put on non-sterile gloves.

2. Clean the entire toe with povidine-iodine.

3. Numb the toe with medicine: If you have lidocaine (1% or 2%) without epinephrine, keep reading to learn how to perform a digital block, i.e. numbing, of the big toe.
Note: Make sure the lidocaine does not have epinephrine in it. Epinephrine is a vasoconstrictor, meaning it clamps down blood vessels. This can prevent circulation to the toes. If you stop circulation with medicine, you have no idea how long it will last, and you could kill the tissues in the toe. Your patient won’t feel you remove their toenail, but in a few weeks their toe may fall off! Bottom line: Never use epinephrine on the fingers, toes, ears, penis, or nose.

3A.) Load the lidocaine into the syringe. I have no idea what kind of container of lidocaine you will have, but the standard container is a small jar with an injectable, rubber stopper. Remove the cap and clean the stopper with alcohol. Draw back the syringe to draw in about 8-10 mL (or cc’s) of air. Then push the needle into the rubber cover. Inject the air into the jar of lidocaine; this prevents a vacuum from forming after repetitive uses. (If the jar is full, you may have fill the syringe a bit at a time so the rubber cover doesn’t pop off when you inject a full syringe of air – I learned this the hard way!) Invert the jar so the needle tip is completely covered with lidocaine. Draw back the syringe to the 8-10 mL mark. Remove the needle from the jar. Point the needle up. Tap the syringe to get the majority of the air bubbles to the top. Slowly depress the syringe to express the air bubbles from the syringe. Usually a little of the lidocaine will shoot out. It is not vital to remove all the air, just as much as you can.

3B.) Find the MTP joint (metatarsophalangeal joint). The first joint next to the big toenail is the PIP joint (proximal interphalangeal). The second joint, and usually larger of the two, is the MTP – it connects the toe to the rest of the foot.

3C.) Find the injection sites. They are about one-eighth inch above the MTP joint (that is one-quarter inch down the toe, closer to the nail). There are three injection sites: one directly on top of the toe, one exactly on the right side, and one exactly on the left side.

3D.) Inject the lidocaine. Always inject a needle perpendicular to the skin. Puncture the skin with the needle and insert to a depth of about 2 mm (skin is about 1.5 mm thick). Pull back on the syringe to make sure you are not in a blood vessel; if you are, you will see a bunch of bright red blood fill the syringe (if this happens, withdraw the needle and try again a little to the side). You will want to inject about 2 mL of lidocaine at each site. This will sting and burn and then go numb.

3E.) Wait. Wait 5-10 minutes for the block to become effective. If need be, you can give another 1-2 mLs if your patient is still feeling pain. When the toe is numb, proceed.

4. Dull the pain with no medicine: If you do not have lidocaine, things are going to be painful. There are topical numbing medicines available, but these are not nearly as effective as an injection. Most of them are in the same family as lidocaine and are mixed with a cream to make application easier. Another option is to try a topical dental pain reliever such as Orajel or Anbesol (these are topical benzocaine), but again this will only take the edge off. A final option, if you have access to it, is ice; cold temperatures can numb a toe pretty well. An ice water (or snow water) bath is likely the safest way to numb a toe; but be mindful that a cold, numb toe is also a sign of frostbite. It’s a careful balance, and I would always err on the side of too much pain. Pain will go away eventually, but a frostbitten toe may never heal. Keep in mind, depending on the person and their pain tolerance, your patient may be able to just grin and bear it.

5. Re-wash the toe with povidine-iodine. Put on sterile gloves. Place a sterile drape over the foot. A small hole in the drape to pull the toe through will keep your surgical field clean.

6. Insert the tip of your closed iris scissors under the corner of the nail on the side it is ingrown. Work the tip down the entire side freeing it from the tissue of the toe. If there are no pain medications, this will be very painful. You should now have the entire side unattached.

7. Split the nail into two pieces. Using a nail splitter, bandage scissors, or iris scissors cut the nail from the free end straight back to the base. You should now have split the nail into 2 pieces (1/5 is the side with the ingrown nail; 4/5 is the healthy side). These pieces are still connected at the root.

8. Apply tourniquet. Some physicians use a sterilized rubber band to wrap around the toe a few times. This acts as a small tourniquet to reduce blood loss which makes it easier to see what you are doing. Having done both, I personally like having a tourniquet in place. Remember to use the tourniquet for the shortest amount of time possible to avoid permanent damage (less than 10 minutes).

9. Remove the toenail. Grab the ingrown toenail with a hemostat. Attempt to grab as much as possible with one bite. Pull straight out toward the end of the toe and to the side at the same time (do not pull up or down or twist). If the nail breaks, just re-grab the remaining nail and pull in the same motion as before. No piece of nail should remain. Some other tissues can look like a nail deeper at the root, but the nail to be removed is hard to the touch of your hemostat.

10. Destroy the matrix. There are a few ways to do this. The most effective and the easiest to perform at home is cautery. Cauterize (i.e. burn) the nail forming matrix (root) in only the area where the nail root was removed. This is probably the most delicate part of the whole procedure. The idea is to burn just the root and not the surrounding tissue – think of the old game Operation. Cauterize the entire area twice to make sure you didn’t miss a spot. Since most people will not have an electrocautery machine, a small soldering iron [with a fresh tip] will work in a pinch (haven’t you read "Patriots" ?). If you have no electricity, you can consider heating up a thin piece of bare wire in a flame to keep it very hot and use small needle nose pliers to hold it. Another method is to apply a Q-tip soaked in phenol solution to the root. This chemically cauterizes the matrix. This is not as effective and you have to buy and store the solution, but it is another option. Again only apply it to the root; it will kill any tissue it touches.

11. Apply antibiotic ointment over the raw tissue. Apply a bulky gauze wrap, but do not wrap it too tight. It will throb as sensation returns.

12. Change the dressing, clean with warm water, and apply topical antibiotic ointment daily. Use acetaminophen or ibuprofen for pain. Avoid strenuous exercise for at least a week.
13. The empty nail bed will fill in with normal tissue in the next few weeks. Your patient will be left with a healthy, but skinnier, toenail.

Surgical Complications
1. Not all the nail was removed or not all of the root was destroyed: This may happen, even to the best of us. The best course of action is to just wait and see if the nail that grows behaves or not. If it does not, just repeat the procedure.

2. Infection: The toe will have some initial throbbing, but should start to improve dramatically in a few days. If your patient is having an increase in pain, swelling, redness, warmth, or drainage, there is likely an infection. If this occurs in the first few days, it is likely a bacterial infection from Staphylococcus aureus. Oral antibiotics are your best choice and are usually very effective.

Any of the following oral antibiotics (unless there is an allergy) should be used for 10 days (search past Survivalblog posts for medication procurement):
Adults
Cleocin (clindamycin) 300 mg three times a day
Augmentin (amoxicillin with clavulanate) 875 mg / 125 mg twice a day
Dicloxacillin 500 mg every 6 hours
Keflex (cephalexin) 500 mg every 6 hours
Children
Cleocin (clindamycin) 30-40 mg/kg per day divided in 3-4 doses
Dicloxacillin 25-50 mg/kg per day divided in 4 doses
Keflex (cephalexin) 25-50 mg/kg per day divided in 3-4 doses
If the infection occurs after a week, there is an increased chance it is a fungal infection. Fungal infections can usually be treated by stopping the antibiotic ointment and applying a topical anti-fungal cream such as Lotrimin (Clotrimazole), Nizoral (Ketaconazole), or Naftin (Naftidine hydrochloride).

3. The toe is taking a long time to heal and is dusky in color. Some parts are turning black. What happened? The tourniquet was kept on too long, the toe was kept in/on ice for too long, or the cautery was too deep. Don’t let this happen to you! Don’t keep the tourniquet on for too long. 5-10 minutes should be plenty of time to remove the nail and cauterize – use a stop watch. Remember to err on the side of too little numbing with ice. Be gentle with the cautery – this is a shallow procedure. This is not common, but if this does happen consider oral antibiotics and consider attempting to remove the blackened tissue. This would be a case where attempting to find a physician may outweigh the risks of leaving your retreat.

Things to consider
If an ingrown toenail is really severe, has a severe infection, and is affecting both sides of the nail, it is better to remove the entire nail and not do cauterization. Remove the nail. Let things drain. Let things grow back. If things are heading in the same direction, then you can treat it surgically as described above. It is much safer to operate on a toe that is not infected.

Training
It will be difficult to acquire hands on training for this procedure unless you work in the medical field. One way to see how it is done is to go with a friend or family member who is having this procedure. Let them know that you are interested in health care (that you love the Discovery Health Channel or something like that) and you would be honored to help them through this event. Another option is to do an online video search for “toenail removal surgery”. Keep in mind that every practitioner does things a little different. For example, some use cautery (this has been proven to be the most effective), but some still use the chemical phenol. Some use the tools listed above, and others have their own favorites. There are many ways to skin a cat and to remove a toenail.