ONYCHOCRYPTOSIS OR INGROWN TOE NAIL
=Definition.= Onychocryptosis, or ingrowing or ingrown toe nail,
is a condition in which the lateral edge of a nail has penetrated
through the epidermic layers and has become imbedded in the adjacent
or subjacent soft parts of the lateral nail groove. This abnormal
condition gives rise to a number of complications, viz: simple
inflammation, ulceration, circumscribed or diffused cellulitis
and the formation of proud flesh. These may occur singly or as is
commonly found, the last three in unison. The unclean condition of
people’s footgear, the general unsanitary conditions of the foot, or
maltreatment of ingrown nail in its incipiency, often give rise to
the still graver septic complications which ultimate in a general
septicemia.
A nail then to be classed as an ingrowing nail must be specifically
ingrowing. Mention is made of this fact, which many in their wisdom may
deem superfluous, because so many conditions of callous or helomata in
the nail groove are mistaken for ingrowing nail and their treatment
as such is not only useless, so far as a cure is concerned, but is
decidedly detrimental to the comfort of the patient and to the future
general condition of the nail involved.
=Etiology.= A large percentage, perhaps larger than most people
imagine, of ingrown nails arise from the injudicious cutting of the
part by an inexperienced person. Directly after an amateur operation
upon a painful nail, acute symptoms of ingrowing nail do not
necessarily develop--although it does happen in many cases; but the
etiology of a great number of acute and well defined cases of ingrown
nail, as stated, can be traced primarily to self-inflicted nail injury
at some previous time.
The changes taking place in the nail and in the tissues of the nail
groove after the removal of the lateral border of the nail, are
pronounced. Take, for example, the great toe nail, as this is the most
easily studied on account of its size and at the same time is the most
general seat of troubles of this nature.
The nails are placed on the dorsal surfaces of the toes as a means of
protection to the expanded extremities of the distal phalanges. Perhaps
the Divine Providence in moulding his masterpiece, man, foresaw the
advent of modern footgear and realizing its baneful effect upon the
human extremity, developed upon the great toe a heavy nail from which a
great deal of protection for the more tender tissues beneath might be
obtained. At any rate, the great toe nail today bears the brunt of the
pressure from our leather footgear and for that reason is probably the
seat of so many painful afflictions.
The free edge of the normal great toe nail is found to be more
flattened and expanded than the posterior portions of the nail nearer
its root. This flattened expansion holds the softer tissues of the end
of the toe and of the lateral border of the nail groove in place under
the nail and also prevents them, if allowed to remain untouched, from
crowding up or around the nail at any quarter. But allow the free edge
and the lateral border of the nail to be removed, and particularly
by inexperienced hands--and observe what takes place. These softer
tissues which were normally held in place by the free borders of the
nail, fill up the spaces left by the removal of the nail borders. Even
this condition, were the nail to remain stationary and cease to grow,
would not be conducive to great pain or inconvenience. But the nail is
being continually pushed forward by the formation of new cells at its
posterior extremity. This is embedded in the posterior nail fold, and
when the newly formed portion of the same width as originally found
arrives at the point where the softer tissues are crowded up and into
the space left by the removal of the borders of the nail, instead of
growing over them and forcing them back into their normal position, it
finds this impossible, and grows into them.
From the foregoing we are not to take it for granted that all cases
occur from injudicious cutting of the nail’s lateral borders. Short
and tight shoes and hose are in some cases the exciting causes of
ingrowing nails and, from observation, we are led to believe that
while the actual ingrowing nail is not hereditary, nevertheless the
predisposition toward nail inversion is manifest through an entire
family or even through a generation.
In the case of tight footgear or hosiery, the cause is the crowding
of the great toe against its neighbor, forcing the softer tissues of
the nail groove and flap to be crowded against the lateral edge of the
nail. In these cases the principal site of occurrence will naturally
be the outer sides of the great toe; in fact, in most cases, this
groove will be found to be the most general site of occurrence. The
soft tissues of the nail flap being crowded over and around the nail’s
lateral edge, there naturally follows an irritation in the groove,
caused by the nail rubbing upon these tissues which, in time no doubt
leads to ulceration of the parts with the accompanying inflammatory
symptoms.
Uric acid diathesis may in one sense be said to be the cause of some
cases of ingrown nail in that when patients so suffer, the nails
are prone to chip off at the edges leaving the latter ragged and
so allowing a chance for irritation from the saw-like projections,
ultimating in an ulcerated condition of the wounded parts.
=Complications.= Other than the general inflammatory conditions
brought about in connection with the ulceration caused by the edge of
the nail penetrating the softer tissues, proud flesh is probably the
complication most generally met with in these cases.
Proud flesh, thus produced, is due undoubtedly to the constant
irritation of the nail upon the exposed surfaces of ulcerated area.
It forms in many shapes and the mass developed depends largely upon
the length of time the condition is allowed to progress without proper
treatment. The excess growth is usually found covering the whole
exposed area, or only forming in a teat-like prominence with a small
circumscribed base and expanded extremity. The pain to the patient is
undoubtedly augmented by the presence of proud flesh and the discharge
from the ulcerated areas is thereby increased. Hemorrhage from the
movement of the toe in walking is prone to occur and the general
unwholesomeness of the part is thus exaggerated.
In some cases the production of these exuberant granulations takes
place under the body of the nail as well as in the groove or on the
flap and they are not clearly discernible until the imbedded portion of
the nail is removed, when they will be seen to crowd upward into view.
Any open wound upon the surfaces of the foot is very liable to septic
infection. Regardless of the cleanly care one may give his feet and
regardless of the washing of hose, infection will still take place,
and only naturally so. The feet are coming constantly in contact with
septic surfaces and the inside of a shoe presents large areas for the
resting place of countless microorganisms in that it combines the three
elements which are best suited for the growth of bacteria, viz: heat,
moisture and darkness.
Ingrown nails are even more prone to infection than is a lesion in
connection with an heloma or a fissured toe web, and in many instances
where cases have been allowed to run for some time before the surgeon
or podiatrist is called into consultation, infection has already
occurred.
In connection with septic cases, abscess cavities are often found
immediately in the nail groove, under the body of the nail itself or
with a suppurative sinus burrowing backward under the posterior nail
fold and involving the whole of the matrix in an acute suppurative
process. In exaggerated cases, the cellulitis may be diffused
throughout the whole digital region. However, these cases are rare, as
walking has become well-nigh impossible long before this takes place
and the patient will have been under scientific treatment before the
case has reached such proportions.
=Treatment.= From the standpoint of the podiatrist, there are two
distinct methods of operative technic in ingrown nail cases, the
radical and the palliative. They differ as to the exact technic of the
removal of the ingrown portion, but agree on practically all other
points.
In that but for the first part of the operation these two methods
are similar, they will be discussed separately as to that alone, and
the post-operative procedures and dressing of both will be combined
into one general discussion. Under each heading the treatment of the
surrounding tissues is mentioned, but the reader is referred to the
heading “Prophylaxis” for a thorough and comprehensive discussion of
the various procedures necessary to their proper care.
=Asepsis.= Proper aseptic precautions must be observed in all lesions
and particularly so with ingrown nail cases. As has already been
stated, conditions of this nature are prone to infection because the
surfaces and recesses or the nail groove present excellent lodgment for
bacteria, and this point should always be borne in mind.
The parts should first be thoroughly cleansed with ether. This removes
all greasy or oily matter from the field of operation and allows the
antiseptic solutions subsequently used to come in direct contact with
the affected surfaces.
Some effective antiseptic should then be used as a spray to prevent the
washing in of bacteria from the surrounding parts. There are a number
of solutions which are useful for this purpose; liq. zinci et alumini
compositus, N.F., and liq. zinci et ferri compositus, N.F., are both
highly recommended. Liq. cresolis compositus may also be used with
excellent results, although it carries the somewhat disagreeable odor
of the cresols. These solutions are all active in strengths ranging
from two to five per cent.
Iodine is unquestionably the best antiseptic that can be applied to the
field of operation, but as its discoloration of the tissues prevents
the operator from visually observing geographic points he may need for
further diagnosis, and as this drug also acts as a corrosive to metal
instruments, it is found advisable in many instances to refrain from
its use.
As a substitute for iodine, alcohol is the next most efficient
germicide. Sixty per cent. strength is recommended, as in that
proportion it has greater penetrative and antiseptic value than the
stronger solutions.
The alcohol, applied by means of a cotton wound applicator, is rubbed
into the parts, or a pledget of sterile cotton or gauze, saturated in
the solution, may be applied over the field and allowed to remain for
two or three minutes prior to operation.
When the operator has followed the foregoing, or a similar line of
procedure, the removal of the ingrown portion of nail may be begun.
For simplicity’s sake, the methods of treatment will be discussed,
beginning with the uncomplicated case, and the various complications
will be considered under separate headings.
UNCOMPLICATED CASES
=Removal of the Ingrown Portion.= Having obtained thorough asepsis of
the affected and surrounding areas, the operator by means of a small,
blunt sterile probe, should endeavor to locate the exact position and
size of the ingrown portion of nail, which should then be removed by
means of a sterile nail chisel.
=The Nail Chisel.= This instrument is a narrow steel blade set in a
long or short handle, as the operator desires, the operating end of
which is slightly oblique so that, upon direct pressure, the blade cuts
in a diagonal manner. This is for the purpose of minimizing the danger
of penetration into the nail bed. In the radical operation a broader
and heavier chisel is sometimes used so that the softer tissues may be
included in the incision.
=The Radical Method.= Proper antiseptic precautions having been
taken, the circulation is cut off at the base of the toe by the
application of a tourniquet. Under local anesthesia, induced preferably
by the hypodermatic injection of novocaine, 1%, the nail is split
longitudinally to the root with an ingrown nail chisel, care being
taken not to split the nail at or near its centre--a procedure
practised by some surgeons. When the nail has been cut through the
root, the free portion is grasped with an artery forceps and is lifted
out of the nail groove. It is often necessary to dissect the nail from
adhesions which have formed.
The proud flesh, should any be present, is now snipped off with a pair
of curved scissors and if necessary a portion of the enlarged nail flap
is also included in the cut. The soft tissues should be cut so that the
structure remaining appears normal in size.
The nail matrix is thoroughly curetted over its entire exposed area,
as is the nail bed along its whole surface to the distal end. This
procedure must be thorough to insure against recurrence. Bleeding is of
a capillary type and is easily controlled by digital pressure.
=The Palliative Method.= With a sterile nail clipper, a small cut is
made on the affected side in the free edge of the nail. The chisel is
then placed in this notch and gentle yet firm pressure is exerted so
that the instrument cuts through and splits the nail.
The cut made is in the shape of an arc, following as nearly as possible
the normal line of the lateral edge of the nail. The broadest part of
the arc is at the anterior or free edge of the nail, gradually reducing
the width of the piece to be removed until the lateral edge is reached.
In this way a clean sweeping cut is made which does not invade and
consequently does not irritate the tissues about the nail root.
The palliative method of operative technic in ingrown nail cases is
based on the theory that the condition is not one of a misdirected
growth of the nail, but rather a case of the soft tissues adjacent to
the nail crowding up, around and over the nail proper; and that the
nail body as it pushes continually forward, cannot force this mass back
into its normal position and, of necessity, must grow into it.
There is no lateral hypertrophy of the nail nor does it present any
misdirected growth.
[Illustration: ONYCHOCRYPTOSIS (SUPPURATING)]
Keeping this theory in mind, it would seem unnecessary and poor
surgery to remove the portions of the matrix of the nail from which
the affected side develops when in reality it is not the nail that is
at fault but rather the soft tissues adjacent to it; and the ingrowing
of the nail body is purely secondary to the displacement of these soft
tissues. As ever in surgery, however, it remains a matter of judgment
as to which operation should be done so as to obtain the best results.
When the palliative methods fail to be effective, the radical operation
is permissible--never the reverse.
The palliative method has for its object the removal of the portion of
nail whose irritant free border is embedded in the tissues and, this
accomplished, to treat these softer tissues in such a manner that they
will become normal as to position and all else. By such a manner and
method of treatment, sufficient space is obtained at its lateral edge
for the nail to grow to its full width and in time to become perfectly
normal as to appearance, function and feeling.
The straight nail chisel, in most instances, can be used, but where
the ingrown portion of nail is deeply embedded, a right or left curved
chisel can be substituted with greater success. The curve in this
variety of chisel aids the operator in lifting the nail out of its bed,
while at the same time the cutting process is not hindered.
=Dressing.= Following the removal of the offending portion of nail, the
operator should make sure that no nail slivers, previously existing
or of his own making, remain in the nail fold. Assured of this, the
parts should then be thoroughly irrigated either with alcohol, 60%, or
mercuric chloride, ¹⁄₄₀₀₀. Hydrogen peroxide may be used as an irrigant
where pus is present, but it should not be depended upon as a germicide
as its action is very transient and superficial. A final dressing is
then put in place.
There seems to be a wide diversity of opinion as to what constitutes
a proper dressing after the nail has been removed. Whatever else
individual experience may show to be useful, the dressing should be
one embodying antiseptic, astringent and healing properties. The
antiseptic, surely regardless of what other action is to be desired;
the astringent, so that inflammatory symptoms may be speedily combated
and the ulcerated areas contracted; and the healing so that granulation
may be the more speedily promoted.
Three forms of dressings may be classified: the wet; the dry; the
ointment.
=The Wet Dressing.= The nail groove is packed with a small piece of
sterile gauze. Care should be exercised that a thin fold of the gauze
be placed under the edge of the nail between it and the tissues into
which the ingrown portion of nail was embedded. A piece of sterile
gauze, of about three or four thicknesses and about two inches square,
is then placed over the affected fold of the nail, covering the
inflamed area and extending over the nail itself. This pledget is then
saturated with a solution of the operator’s choosing to meet the needs
of the case under treatment. Two solutions seem to be favored above all
others in this connection: mercuric chloride, ¹⁄₅₀₀₀, or weaker, and
liq. aluminum acetate. The latter solution is at most times preferable,
as it possesses antiseptic qualities (nearly, if not equal to corrosive
sublimate without exhibiting the toxic properties of the latter) and
produces an astringent and antiphlogistic action on the tissues. Strong
germicidal solutions such as the mercuric chloride are at times found
to be decidedly detrimental, in that they not alone cause maceration
and desquamation of the skin, but in some instances, if too strong,
they destroy the newly formed connective tissue granules.
The gauze square which covers the whole end of the toe, and which is
saturated with either solution just described, is held in place by a
roller bandage or by adhesive strips.
The usual method of applying these strips is to place one on each side
of the gauze square, adhering them over the end of the toe and to and
on the skin, and one over the centre of the dressing, carrying it over
the end and down to and on the plantar surface of the toe. A circular
strip is then carried around the toe, over the posterior end of the
dressing, thus binding down the ends of the three strips previously
applied.
No impervious covering such as gutta percha, oiled silk, etc., should
be used in this instance, or, in fact, in any condition where the skin
is broken. The warmth and moisture produced by such a covering is
congenial to the growth and development of hostile bacteria.
The wet dressing, then, should be left uncovered so that evaporation
may take place and a quantity of the solution used should be
prescribed for the patient, so that the dressing may be moistened with
it from time to time. The dressing without impervious covering is
antiseptic and heat reducing because of the evaporation and frequent
replenishment of the solution.
=The Dry Dressing.= Dry dressings in this sense consist in the
application either of plain, dry, sterile gauze packed in the nail
groove and unmoistened, or dusting the affected parts with some
antiseptic powder to maintain asepsis in the wound and to bring about
normal granulation.
Of these two forms of dry dressing, that constituted by the plain dry
gauze is productive of better results than are obtained by the dusting
powders. A lesion caused by the nail penetrating the soft tissues of
the nail fold, in the process of healing, necessarily discharges a
certain amount of waste material produced in the tissue repair. In
consequence, where a dusting powder is used, the serous discharge at
times combines with the particles of the powder to form a crust which,
in the confined areas of the nail groove, often becomes equally as
irritating as was the ingrown nail itself.
However, in some instances dusting powders may be used with impunity
and many practitioners favor and report success in their use.
Aristol (thymol iodide), dermatol (bismuth subgallate), bismuth
subnitrate and boric acid (powder), preferably the first two named,
may all be safely used in the treatment of ingrown nail cases. Aristol
depends upon the liberation of iodine for its antiseptic action while
the two bismuth salts, the subgallate and the subnitrate, combine
marked astringent properties with their antiseptic qualities.
After the powder is dusted into the affected groove, a thin layer of
sterile gauze is packed lightly under the lateral edge of the nail and
a cocoon dressing is placed over the whole.
This form of dressing is applied until resolution of the inflammatory
process and granulation of the wound has taken place.
=The Ointment Dressing.= All ointments are necessarily of fatty or
oily consistency and, in consequence, when applied over a surface
excreting a serous discharge, are liable to confine this discharge
to the affected areas rather than allow it to be absorbed by the
gauze dressing, and so drain the wound. For this reason the use of
ointments on discharging surfaces is not particularly recommended. Many
practitioners use them, however, and presumably with beneficial results.
Two classes of ointments may be used in this connection: antiseptic and
stimulating. Under these headings the following are suggested: sulphur,
10% (vaseline or lanolin base); ammoniated mercury (white precipitate),
5%; balsam of Peru, 10%; scarlet red (medicinal Biebrich), 4%.
The ointment is placed in the nail groove by means of a spatula, and
sterile gauze is packed lightly under the nail, holding the ointment in
place. This is covered with a cocoon dressing and is renewed until the
parts regain their normal condition.
COMPLICATED CASES
=Proud Flesh.= The development of unhealthy, exuberant granulations is
a common occurrence in connection with ingrown nail cases, especially
when they have been allowed to progress before proper treatment has
been inaugurated.
In all cases the primary steps in the treatment are essentially similar
to those described under “uncomplicated cases.” Proper asepsis and
antisepsis are at all times to be strictly observed, and any ingrown
portion of nail should in all cases be first removed before additional
treatment is administered.
The speedy and complete removal of the unhealthy granulations is at
all times essential. This may be accomplished either by excision, by
the actual cautery or by the use of escharotics. The operator must
always remember that the presence of proud flesh in a wound not alone
retards the normal healing process, but also prevents the wound from
healing without the formation of an abnormal amount of new tissue. If,
for instance, a mass of proud flesh the size of a pea were present
in connection with an ingrown nail and allowed to remain without
further treatment, the tissue would in time present a perfectly normal
appearance. That is, the exuberant granules would sooner or later
develop an epithelial covering which would be of like appearance to the
normal surface of the skin. But in doing so, the tissues would still
retain the shape and size of the original mass of exuberant granules
and we would find a teat of tissue, the size of a pea, jutting out of
the normal surface of the nail groove.
Keeping in mind, then, that to obtain a speedy and normal healing
action in a wound the proud flesh present must be eradicated, it should
appeal to the operator that the quickest means for its removal must be
the best. Two quick and complete methods for obtaining this desired
result are found in (1), excision (by the use of the scalpel or curved
scissors), and in (2), the actual cautery.
[Illustration: BEGINNING INGROWN TOE NAIL]
=Excision.= Excision of the proud flesh cannot be resorted to in all
cases, but in most cases at least the larger portion of the exuberant
granulations can be removed in this manner.
The condition in which the use of the curved scissors is particularly
advocated as most efficient is that in which the mass of proud flesh
is found in pendulous form, where its base is narrow and covers but
a small area and where the mass expands into an enlarged extremity.
In cases where the proud flesh is found generally throughout the nail
groove, and in some instances under the lateral edge of the nail
itself, the scissors or scalpel cannot be used with good effect, if at
all. Then of course other means must be employed.
=Method of Procedure.= After the field of operation has been thoroughly
sterilized and the ingrown portion of the nail has been located and
removed, the exact situation and amount of proud flesh is ascertained.
If at all practical, a sterile scissors (preferably of the curved
variety) is inserted under the granulating mass and the whole is
quickly snipped off at its junction with the normal integument. Where
the mass is considerable, it will be found advisable to ligate the toe
at its base by means of a few tight turns of adhesive tape or by the
use of a rubber ligature. This precaution will lessen the resulting
hemorrhage and it can be more readily controlled.
Where the amount of proud flesh to be excised is small, the blood flow
is easily arrested by digital pressure.
It will generally be found conducive to the best results to anesthetize
the parts by hypodermatic injections of novocaine or by means of the
ethyl chloride spray. This is not necessary in every instance, however,
as the advisability of producing anesthesia depends upon the amount of
tissue involved and the nervous condition of the patient.
After the exuberant granulations have been cut off, Monsel’s solution,
adrenalin chloride or some other styptic is applied to the bleeding
capillaries.
It may be found advisable to apply silver nitrate, 50%, or even nitric
acid, c.p., to the bleeding parts. This serves not alone to check
the hemorrhage, but the escharotic action tends to destroy whatever
remaining shreds of the proud flesh may still be present.
The oozing arrested, the ligature is removed. The nail groove is packed
firmly with sterile gauze (firmly, so as to further check the vascular
supply to the parts) and a wet dressing of liq. aluminum acetate is
applied. In the event of no further recurrence of the proud flesh,
the case is treated in any of the ways described under “uncomplicated
cases.”
=The Actual Cautery.= The electric cautery presents a quick and sure
means by which proud flesh may be destroyed. Local anesthesia should
first be induced by means of a hypodermatic injection of novocaine,
1%, or by use of a freezing spray, such as ethyl chloride. In most
instances the use of the ethyl chloride will be found sufficient
for the needs of the case although its anesthetic effect is quite
superficial and transient. Novocaine, on the contrary, is both lasting
and complete in its effect.
The argument against the use of the actual cautery is one of humaneness
rather than one of science. Regardless of the lack of sensation
produced by the anesthetic, patients will rebel at the sight of a white
hot cautery. The mental shock of seeing one’s flesh seared by a hot
iron is pronounced, and at the present time no podiatrist can take
liberties with the patient’s feelings as does the surgeon, without
jeopardizing his reputation and diminishing his clientele. On the other
hand, while the mental anguish of the patient may be greater during the
use of the actual cautery, the subsequent suffering is much less than
that following the application of an escharotic.
After the use of the cautery, a wet dressing of liq. aluminum acetate
or a solution of boric acid and alcohol, equal parts, may be applied
and renewed until all acute inflammatory symptoms have subsided when a
dressing may be employed to hasten granulation.
=Escharotics.= The use of caustics for the destruction of proud flesh
is probably the most generally used method in vogue today. Nitric acid,
caustic potash and silver nitrate, either in fused or in solution form,
may all be used in most every instance.
Inability for any reason to resort to the use of a curved scissors,
the scalpel, or the cautery compels us to look among the caustics
for an agent to accomplish the desired results. Keeping in mind the
aforementioned fact, that the quickest means for proud flesh removal or
destruction is the best, we naturally lean toward the strong corrosives
as a means to bring about this end.
=Nitric Acid.= Nitric acid (aqua fortis), in all probability, is the
most efficient member of this class of drugs, as its action is both
energetic and penetrating. In cases where the exuberant granulations
are found involving the entire nail fold and in no particular localized
area, aqua fortis is found very useful. Usually one application is
sufficient to destroy all vestige of the unhealthy tissue, but in
extreme cases added treatment may be necessary.
Care is taken to cover the surrounding healthy integument with some
greasy substance (vaseline is generally preferred) to prevent the acid
from coming in contact with it and avoiding the consequent bad effects.
The acid is then applied by means of a cotton wound applicator (wooden
applicators are preferred, as they are inexpensive and may be thrown
away after being used) or a glass rod. The nail groove should be firmly
packed with sterile gauze and a wet dressing of liq. aluminum acetate
or of bichloride of mercury, ¹⁄₅₀₀₀, or a boric acid and alcohol
solution, equal parts, should be applied over the affected parts. At
the next examination, any remaining shreds of the unhealthy granulation
are to be looked for and, if found, another but lighter application of
the acid should be applied. It is wise to remove the eschar caused by
the previous application so that deeper penetration and more efficient
action from the drug may be obtained.
This is continued until all remnants of the proud flesh are destroyed,
when the toe should be dressed to induce speedy and healthy granulation.
=Caustic Potash.= Potassium hydroxide (caustic potash) may be used
in place of nitric acid for the destruction of proud flesh. The
preference for the latter seems to be due to the fact that wound’s
caused by the action of nitric acid are prone to heal more rapidly than
those due to the use of caustic potash; also because the action of aqua
fortis can be more readily counteracted should the need for such action
arise.
Caustic potash should be used with care, the same precautions to
protect the healthy tissue being taken as in the use of nitric acid.
Apply caustic potash on a small cotton wound applicator, packing the
nail fold with sterile gauze to be followed by a moist dressing of liq.
aluminum acetate.
=Silver Nitrate.= The use of the silver stick or a strong solution of
the salt to destroy any great amount of proud flesh is not advocated.
In the first place the caustic action of silver nitrate is due solely
to the nitric acid generated by its use, and so the aqua fortis
should be used to obtain a speedier and more energetic removal of
the unhealthy tissue. Secondly, silver nitrate coming in contact
with the albuminous tissue, decomposes, oxidizing it and forming a
metallic deposit on the surface which becomes an impermeable eschar.
This hard crust not alone prevents the silver salt from penetrating
into the tissues--the action of silver nitrate is thus called
“self-limiting”--but also being unyielding, acts as a direct irritant
to the denuded tissues.
Silver nitrate is, however, particularly efficacious after the great
amount of the proud flesh has been removed by means of excision; in
this situation it acts as a styptic to arrest the capillary flow of the
bleeding stump, and as a mild caustic to destroy the remaining shreds
of the unhealthy granulation. It is also a beneficial application for
hardening the tissues of the nail fold to prevent further recurrence
of the ingrowing nail. This subject will be fully discussed under
“Prophylaxis.” After excision of the proud flesh, silver nitrate should
be used in solution of fifty per cent. and the toe dressed as has been
previously described.
=Burnt Alum.= Burnt alum is still another remedy used in podiatry for
the destruction of proud flesh. Its use is not now favored for that
direct purpose, but there are some situations in connection with the
treatment of the condition in which it may be used with good results.
It is the least energetic of all the escharotics herein mentioned,
and many prefer to class it rather as an astringent. The burnt alum
is dusted in the nail groove directly on the mass of proud flesh and
the groove is then packed with sterile gauze. Because of its extremely
mild action, comparatively speaking, burnt alum will not accomplish its
work of destruction with the rapidity nor the completeness of the other
mentioned drugs; moreover it causes considerable irritation and pain to
the patient. The modern practitioner is inclined to relegate this drug,
as a caustic, to the shelf, to be used only in cases where a strong
astringent action is desired.
=Liquor Ferri Subsulphate.= Monsel’s solution has been used to dry up
unhealthy granulations because of its astringent action rather than on
account of its caustic properties.
=Treatment of Acute Infective Inflammations.= Infection is in all
probability more generally met with in connection with ingrown nail
cases than in any other ailment primarily occurring on the foot. The
state in which the toe may be found is dependent upon the length of
time the case has progressed without proper treatment. Cellulitis may
be circumscribed or diffused, and lymphangitis, both of the reticular
or tubular variety, may be present.
Following the usual antiseptic and aseptic precautions relative to the
field of operation, the operator’s hands and the instruments, drainage
of the suppurated areas must first be obtained.
In the average case, an abscess cavity is usually found in or adjacent
to the lateral nail fold, and in many instances the pus sac will be
punctured during the removal of the ingrown portion of the nail. It
is sometimes found necessary to remove an overlying portion of nail,
other than the ingrown portion, to give free access to the suppurating
process and to afford drainage for its purulent discharge. A sterile
chisel of the straight variety is generally used to accomplish the
removal of the ingrown portion of nail, care being taken that the
cutting edge is inserted deep enough to penetrate only the nail and not
to pierce the underlying soft parts.
Some practitioners do not advocate the removal of portions of the
nail and prefer rather merely to drill a hole through the nail body
and excavate the pus through this channel. No doubt circumstances
alter cases, but the writer would prefer having the septic tract
wholly exposed so that thorough irrigation and proper treatment may be
accomplished.
Having given free drainage to the pus cavities, the parts should again
be sprayed with alcohol, 60%. Hydrogen peroxide, which manifests its
greatest efficacy in pus cases, should then be freely applied until
ebullition ceases.
In cases where the sinus is small and deep and an ordinary cotton wound
applicator is too large for insertion into its recesses, a wooden
applicator tipped with iodine (these applicators already prepared are
now on the market) will be found fine enough for this accomplishment.
There is also on the market a fine, hollow, flexible needle, with
a bulbous extremity in which there is an opening, that fits any
hypodermic syringe. Two or three drops of iodine are drawn into the
barrel, the needle is inserted into the sinus, and its contents are
evacuated by piston pressure. This enables the operator to get the
drug down into the sinus so that it comes into direct contact with its
deepest surfaces. This needle is made of a non-corrosive metal.
The next point to be considered is the form of dressing to be used.
If the case has progressed to a point where the operator feels the
necessity of a surgeon’s advice, the latter should by all means be
called in as a consultant. The writer feels, however, that in most
instances the modern practitioner of podiatry is well equipped to
successfully treat even severe cases of this nature.
The affected nail groove is packed with sterile gauze and a large
piece of the fabric, of several thicknesses, is placed over the whole
inflamed area. This is saturated with a solution of mercuric chloride,
¹⁄₅₀₀₀, and is remoistened at intervals by the patient so that it is
constantly wet. In some cases it may be wise to have the patient remain
in the office several hours to make sure that the infected parts are
kept constantly immersed in a solution of mercuric chloride, ¹⁄₅₀₀₀.
This treatment has been found to be extremely beneficial in reducing
the inflammation so that a moist evaporating dressing, as described
above, may be safely applied. Rest is another feature to be employed
in the treatment of these cases. The patient should be instructed to
refrain absolutely from the use of the affected parts until such time
when the inflammatory conditions have subsided or are under control.
The podiatry patient as a rule is loathe to have his or her energies
in any way curtailed, but the mention of “blood poisoning” is usually
sufficient stimulus to send the patient to bed when so ordered.
=Prognosis.= The prognosis in all cases of ingrown nail under proper
treatment is favorable. The length of time elapsing before a cure is
affected is of course dependent upon the condition of the toe and the
general condition of the patient.
In cases where the nail penetration is slight, and the inflammatory
conditions are in their incipiency, one or at most two treatments will
be sufficient to heal the ulceration and to restore the toe to its
normal condition. Complicated cases necessarily take longer to relieve
and longer to cure.
The surgeon is still rather reluctant to believe that an ingrown
nail can be cured without removal of the affected half of the nail,
the lateral nail fold, and a portion of the matrix. This method of
procedure in nearly every instance incapacitates the patient for fully
two weeks and it is doubtful whether anything is gained (taking all
matters into consideration) over the methods of ingrown nail treatment
as here outlined.
The surgical argument is based on the contention that unless the matrix
underlying the affected nail be removed, the nail will again grow into
the tissues. This is unquestionably so, but in a majority of cases, as
explained previously, the trouble is not due to a misdirected growth
of the nail, but rather to the tissues surrounding the free edge and
lateral nail border crowding up, around and over the nail.
It may then be safely stated that an ingrown nail properly treated and
which has been subjected subsequently to proper prophylactic measures,
is curable; not temporarily, but permanently.
PROPHYLAXIS
In considering the measures employed by which the general condition
of the nail may be improved so as to prevent a further recurrence of
the ingrowing tendencies, we will make, for simplicity’s sake, six
divisions. Five of these relate to the nail itself and to the subjacent
tissues, and one to the footgear and hosiery of the patient.
=1. Thinning the Nail Through Its Long Axis.= When the acute
inflammatory symptoms have subsided and the ulcerated areas healed, in
other words when the toe and the nail have returned to normal, measures
should be taken to prevent the latter from becoming again ingrown.
With a rotary file, the centre of the nail should be ground to a paper
thinness through its long axis. What is accomplished by this procedure?
The nail is normally convex on its outer surface and the apex of its
dome is the centre of the nail body. This portion, being the greatest
point of elevation, naturally receives the brunt of the pressure
from the shoe. If the nail, then, is allowed to remain thick in the
centre of its body, the shoe pressing upon it will find the nail
unyielding and in consequence will cause its lateral borders to be
forced down into the nail grooves. By thinning the body of the nail
to such an extent that it becomes thin and flexible, the shoe presses
upon a yielding surface, in consequence of which the nail “gives” or
spatulates at its centre and the pressure upon its lateral borders is
decreased if not prevented entirely.
Having done away with any untoward pressure which might be brought to
bear on the nail, we next turn to:
=2. Hardening the Nail Groove, and Shrinking the Flap.= In many cases,
after all acute symptoms of the disturbances have subsided, we find
that the flap of tissue adjacent to the once affected nail and forming
the outer side of the groove, is greatly thickened and enlarged.
This must be reduced in order that the new-forming nail will have
sufficient room to develop to its normal width and we must also harden
and toughen the nail groove so that it will present a surface that the
nail, as it grows out, will not be able to penetrate, should it be so
inclined.
Silver nitrate is the most generally used and most efficient agent to
carry out a treatment of this kind. Solutions varying in strength from
5% to 50% are recommended, and the selection depends on what is to be
accomplished and the length of time which may be given to the treatment.
By persistent use of silver nitrate solution, 50%, an enlarged and
thickened nail flap may in time be reduced to normal. Applications
about one week apart--in some cases ten days or two weeks to
intervene--will usually work wonders in conditions of this kind. The
groove should be thoroughly cleansed and dried and the silver solution
should be applied on a small cotton wound applicator and painted well
down under the nail and over the tissue in the enlargement. A dressing,
usually cotton and collodion, is then applied and allowed to remain
undisturbed until the patient’s return. The action of this solution is
astringent and sedative. It is bound to reduce the chronic inflammatory
symptoms that may be present and, acting as an astringent, it gradually
shrinks the enlarged flap until the normal line of the lateral nail
fold is reached.
During the treatment, there is absolutely no pain nor inconvenience to
the patient. Care should always be exercised that the silver solution
be not applied if any hemorrhage has been caused in the removal of a
previous eschar, as it is sufficiently caustic to cause ulceration
should it come in contact with such a denuded surface. Packing of the
nail groove will be discussed under the sub-heading “Packing.”
Subsulphate of iron (Monsel’s solution) may be used in the treatment
of cases of this nature, but its action as an astringent in this
connection is so mild that it is of necessity a slow process to effect
a complete cure.
The solution, usually applied to the groove on gauze, is allowed to
remain. In fact, the patient is often advised to procure a quantity of
the drug and keep the gauze moistened.
The patient should be seen at periods of about a week or ten days, when
both the dressing and the eschar caused by the action of the iron salt
are removed. Fresh gauze is packed under the nail and the treatment
continued.
Ferric chloride has much the same action in this connection as the
subsulphate, but this drug has never been so popular, for the reason of
its greater irritant qualities, few of which are to any degree manifest
in Monsel’s solution.
Ointments or collodion containing large percentages of salicylic
acid--as high as sixty to seventy-five per cent.--are sometimes used
to destroy an enlarged nail flap by strong disintegrative action. The
ointment is usually prepared on a cerate base and sufficient wax is
added to thicken the paste so that the tendency to melt and run over
portions of the integument, where its action would be detrimental, is
minimized.
The ointment is applied in the groove and over the top surface of the
mass to be destroyed and is allowed to remain for a few days when
the disintegrated portion is removed and another application made.
This action of salicylic acid, used in considerable strength, is at
times painful and cannot be borne by every patient. The treatment is
a good one, however, and is rapidly coming into the prominence and
popularity it deserves. Salicylated collodion is similar in action to
the ointments containing salicylic acid, and the same general procedure
holds good for both applications. The collodion is applied on all
surfaces of the mass, is covered with a cotton and collodion dressing
and a second application is made upon the removal of the disintegrated
portion.
It is sometimes advantageous to alternate the silver nitrate treatment
with that of salicylic acid. An application of the ointment or the
collodion is made and upon removal of the disintegrated portion, the
silver solution is applied. After the lapse of about two weeks, the
salicylic acid is again applied and the treatment continued alternately
in this manner until the desired result is obtained.
=3. Packing.= We here come to one of the most important procedures
necessary to a successful prophylactic treatment of an ingrown nail.
Whether the nail groove is to be packed loosely or tightly is a
question of great import and should be given careful consideration by
the operator. Often the comfort of the patient and always the ultimate
outcome of the case is dependent on the proper packing of the nail
groove as an after-treatment.
There appears to be a great tendency to pack the groove full to
overflowing with gauze, cotton, or what not, and, although there are
some instances where a procedure of this kind is necessary, it is
usually conducive to a great amount of pain to the patient and has a
decidedly deleterious effect on the tissues under treatment.
In general, it is wise to pack the groove as lightly as possible, using
only a small pledget of gauze or cotton and taking care that the fabric
is well under the nail and interposed between it and the tender areas
underneath. It must be remembered that no matter what fabric be used
for packing, it rapidly hardens and becomes more or less irritant to
the tissues. Should the nail groove be packed to such a degree that at
the time of dressing it is unyielding and hard, it is easily realized
what the condition of this dressing will be in the course of a few days.
The only time a nail groove might be tightly packed is in connection
with the treatment of proud flesh when the tight packing tends to
interrupt the circulation to the part and thus aids in retarding the
growth of the superfluous granulations. Another instance when a groove
may be packed tightly is in a case where no inflammation is present
and when it is the desire of the operator to hold the softer tissues
down and away from the edge of the nail so that sufficient room may be
allowed for the nail to grow out and attain its normal width. A word in
connection with this theory. Silver nitrate solutions, twenty-five to
fifty per cent., applied to the groove hardens the tissue by means of
the eschar developed on its surface and a tight packing to hold these
tissues in place is an ideal combination for the prophylactic treatment
of a previously acute ingrown nail case, when by such tight packing
no noticeable inconvenience is caused to the patient. If cotton is
used as a packing it should be rolled into a loose thin pledget, the
finer “point” of which is inserted under the edge of the nail near its
posterior fold, and the thicker end is packed under the nail at its
distal portion. One thickness of gauze is generally sufficient and, at
most, two thicknesses may be used, unless, of course, tight packing is
required.
In connection with this prophylactic treatment it may sometimes be wise
to place a shield of felt or buckskin between the tender part and the
adjacent toe to hold that member away from the affected areas and so
that the medications applied may be allowed a chance to complete their
therapeutic action undisturbed. This shield is not strapped but is
merely placed between the toes, resting on the interdigital web, and is
just high enough to reach the base of the nail and so does not come in
direct contact with the area under treatment.
=4. Allowing the Nail to Grow Long.= The nail should be allowed to
attain as great a length as possible, particularly at its lateral
points, without interference with the continuity of the patient’s
hosiery, and yet not long enough to cause pressure from the toe of the
boot.
This can be best accomplished by cutting the free edge of the nail
in a concave manner. The lateral points are kept, if possible, long
enough so as to extend to a point slightly beyond the distal end of the
nail fold and the rest of the free edge is cut in a circular manner so
that at its centre it is no longer than just sufficient to cover the
anterior edge of the nail bed. This manner of cutting, combined with
thinning the nail body through its central longitudinal axis, prevents
any great amount of pressure from being exerted by the shoe upon the
apex of the nail’s convexity. It will also, to a great extent, prevent
the nail from cutting through the patient’s hosiery. If the whole nail
is allowed to grow long, and its free edge to extend over the end
of the toe, some leverage is bound to be brought upon this extended
portion and in consequence there is a tendency to press the lateral
edges of the nail into the grooves, which, of course, is to be avoided
at all costs.
=5. No Lateral Cutting.= In connection with the length which the nail
is allowed to retain, it is absolutely imperative that no lateral
cutting be done. Some cases of ingrown nail have been observed in even
very young children (in one instance a baby of fourteen months). The
primary cause in every case was found to be the overzealous care on
the part of the parents to prevent just the condition they had caused
by injudiciously removing from time to time the lateral edges of the
sufferer’s toe nails.
=6. Proper Boots and Hosiery.= In addition to the various means for
preventing the recurrence of an ingrowing nail, great care should be
exercised in the selection of the patient’s footgear.
Shoes of sufficient width and length should of course be advocated so
that at no time will the toes be cramped by any degree of pressure.
The wearing of a pointed boot or slipper in which there is not
sufficient width at the ends of the toes to allow those members proper
latitude, should be discouraged. When footgear is worn in which this
cramped condition of the digits is brought about, it will be generally
found that the soft tissues lying adjacent to the lateral edges of the
nail are crowded up alongside the latter and an enlarged and thickened
flap, which is the cause of so much trouble, is formed. Lace boots are
probably the most practical of any in that they may be firmly fastened
about the ankles and over the instep, and thus prevent the foot from
sliding forward and coming in contact with the toe of the boot. Pumps
of all varieties are without a doubt the most detrimental footgear worn
today--for they have absolutely no support or anchorage at the ankle
and, in some cases, patients find themselves flexing the toes in the
endeavor to retain the slipper on the foot.
Hosiery, too, should be neither tight nor short, as a short stocking or
sock may cause pressure upon the toe nails and so be the forerunner of
trouble.