Ingrowing toe-nails are unusual in barefooted people. One of the hazards of a shoe is that it may press on the sides of a patient's big toe over a long period, and make the side of his nail grow into his soft tissues and cause pain, inflammation, and the discharge of pus from his nailfold. Carefully cutting away his nail may relieve his symptoms, but if this fails, more radical surgery is indicated. If his toe-nail is not deformed, you can excise a wedge of soft tissue (A, in Fig. 27-19); but if it is deformed, he will have a more comfortable toe if you remove his whole toe-nail, including its bed. Use a hexagonal incision, excise the distal part of his terminal phalanx, and reflect the plantar flap dorsally. The V-shaped parts of the hexagon at the sides of his toe will make the incision easier to close, make his nail bed easier to remove, and give his toe a better shape. A slightly short big toe is no disability.
Fig. 27-19 INGROWING TOE-NAIL. If non-operative measures have failed, you can excise a wedge from the side of the patient's nail bed (A, B, and C), or you can excise his whole nail bed, shorten his distal phalanx, and turn the end of his toe over as a flap (D, and E).
INGROWING TOE-NAIL INDICATIONS Non-operative measures have failed.
ANAESTHESIA Digital block (A 6.21).
A PLASTIC OPERATION ON THE SKIN FOLD [f41]If the patient's nail is not deformed, excise an elliptical piece of his skin fold and nail bed, as in A, Fig. 27-19. Suture the edges of the incision so as to draw the remains of the fold away from his nail.
RADICAL EXCISION OF THE NAIL BED [f41]If his nail is deformed, make a hexagonal incision round it, as in D, Fig. 27-19. When you cut the distal part, insert your scalpel obliquely in order to prevent the skin flap curling when you close the wound.
Insert a periosteal elevator, or a narrow osteotome into the distal part of the incision, under his nail bed, so as to raise it from his terminal phalanx. Remove the entire contents of the hexagon, including the lateral roots of his nail bed, so as to leave the bone bare and clean. Dissect out and excise the terminal half of the phalanx. Raise the plantar flap of skin and subcutaneous tissue, so as to close the wound.
CAUTION ! The lateral roots of his nail bed may extend round the base of his phalanx, as far as its plantar surface. Be sure to excise them completely.
Fig. 27-20 AMNIOTIC BANDS sometimes amputate a limb in utero, as in the neonate E. If they merely cause a constriction (A), excise the constricted area (B), plan multiple small flaps (C) and do a Z-plasty (D). Kindly contributed by Jim Thornton.