Ingrown nail

Ingrown Nail

Although chronic inflammatory affections of the neighboring skin often produce changes in the form, color and thickness of the nails, these so rarely call for surgical interference that only those conditions leading up to the development of ingrown nail will receive consideration in the following.

Ingrown nail may be due to either a lateral hypertrophy of the nail itself cutting into the soft parts, or to the primary hypertrophy of the soft parts themselves, thus producing the same picture. An accurate determination of which condition represents the original etiologic element is important in deciding upon a course of treatment directed to the radical cure of ingrown nail.

The term “radical cure” does not necessarily indicate the performance of the so-called radical operation, but may result from proper treatment of a down-curved nail edge, or of a diseased nail fold, together with such prophylaxis in foot-gear as is indicated. With sufficient room in the shoe and the removal of offending granulations or cutting nail edge, a radical cure can frequently be effected.

Any inflammatory condition, either of the nail or its matrix, or the tissues contiguous to the nail, may result in the train of symptoms which are indicative of ingrown nail. When, however, any of these conditions has existed sufficiently long to cause ingrown nail to be present, it ceases to be of the first importance; it then becomes necessary to treat the buried nail edge, or the overgrown soft tissues themselves.

The Choice of Method  between radical and palliative operations will depend entirely upon the degree of infection present, and the facility with which it can be reached. Thus, in the event of the entire toe being red and swollen and much purulent discharge being present, there will in all probability also exist much inflammatory tissue and a deep burying of the nail edge.

With a tolerant patient it might be possible to scrape away with a sharp spoon the granulation tissue, and remove the offending nail edge; the gradual improvement sought in ordinary cases cannot be thought of in these cases. It is urgent to relieve the pain and throbbing and to circumvent the dangers of a spreading infection. The sensations of a cutting nail edge have been lost in the more severe development. Should the patient be tolerant of pain, exposure, disinfection and drainage of the infected area is possible, but in most instances the contrary will obtain, and the radical operation with local anesthesia will be indicated.

The possibility of doing an efficient operation will ordinarily determine the method to be employed.

On the other hand there are a large number of cases in which palliative treatment is not only effective but emphatically the method of choice. One might see a degree of burying of nail edge quite as extensive as in the foregoing, with however, only a slight degree of infection. The nail fold may be much hypertrophied and granulation tissue may be abundant. The tenderness and inflammatory condition, however, is not so great as to interfere with the ordinary procedure. There is no danger of a rapidly ascending infection, the nail groove showing no inordinate amount of discharge. It is in these cases that a permanent cure frequently results from the mere removal of the irritating nail edge followed by the disinfection of the nail groove.

It is held by many that all cases of ingrown nail, except those due to a true hypertrophy of the nail, would remain permanently cured were it not for short or badly shaped shoes.

The Palliative Treatment of Ingrown Nail  must necessarily depend upon its original cause. Should it be due to the wearing of improper foot-gear, nothing primarily pathologic in the tissues themselves being present, treatment will be effective only when correct shoes are worn thereafter.

Eczematous skin surrounding a nail or infection of a nail groove or matrix, should be treated as such before sufficient hypertrophy takes place to bury the nail edge. The disinfection and drainage of the groove can usually be accomplished with iodin on a thin wire or wooden applicator inserted to the extreme depth of the groove, followed by the insertion of a narrow strip of gauze. Frequent changes of dressings and extreme cleanliness will cause the early subsidence of these infections. It, however, is to be deplored that in the early stages these cases so rarely obtain treatment.

Elevation of the nail edge is often practiced quite successfully, but in general, this method of treatment is not applicable to the acute stages of the disease on account of the concomitant pain. Either the nail is too thick to be elevated by the insertion of cotton under its free edge, or the soft tissues are too sensitive to admit of the pressure.

The real skill of the chiropodist is called into practice in the treatment of ingrown nail by palliative methods, and he may safely be judged by his results in this class of cases.

It requires discrimination whether to attack the exuberant granulation tissue or the cutting nail edge, and in many instances it will be found that both are necessary.

Much skill is required in removing that part of the nail which is buried without causing pain or bleeding; this is the first necessity for relieving pain and can only be accomplished by a technic acquired through practice, and often redounding more to the credit of the operator than the successful performance of a major operation. A sharp instrument, usually a chisel, is placed against the free edge of the nail so as to cut only through the nail itself and not into the nail bed, with the purpose in mind of removing a wedge-shaped piece of nail of just the size necessary to relieve irritation, and permit of proper drainage and dressing.

Exuberant granulations are best treated either with nitrate of silver applications (50 per cent.) or with tight packing, or both. Disinfection and wick drainage of the entire tract is of the utmost importance.

The Radical Treatment of Ingrown Toe Nail. The operations, as in the palliative treatment, naturally fall into two classes depending on (1) whether the nail originally was at fault, or (2) whether the soft tissues, by inflammatory processes, have hypertrophied and overgrown.

Operations depending on such diseases or malformations of the nail, causing it to grow down into the tissues, should be directed to the removal of the nail, or the offending part of it with its matrix. (See “Hypertrophy ”).

In conditions manifestly due to disease and hypertrophy of the soft tissues, palliative treatment frequently fails, and it becomes necessary to curet the granulating nail fold or to erode it with chemicals.

The best and easiest operation to effect a permanent cure, where this condition obtains, is known as Weber's operation. This operation consists of the excision of an elliptical section of tissue just alongside of the offending nail border, without interfering with the diseased tissues themselves, and suturing the cut edges together in the long direction of the wound. The incisions are made to extend a little further back than the nail and as far forward as possible. They are about a quarter of an inch apart at the centre and meet at these two points. The depth of the section of tissue removed, if sufficiently great, leaves a diamond shaped cavity. When the edges of the wound are brought together the overgrown edge is pulled away from the nail and the further cicatrization of the wound contracting the soft tissues, assures an excellent result.