This chapter discusses the common foot disorders that are likely to present to the ED. Patients with chronic or complicated foot problems generally should be referred to a dermatologist, orthopedist, general surgeon, or podiatrist, depending on the disease and local resources. Melanoma, tinea pedis, diabetic foot ulcers, onychomycosis, corns, and warts are discussed in Chapter 253, “Skin Disorders: Extremities.” Diabetic ulcers are discussed in Chapter 224, “Type 2 Diabetes Mellitus.” Puncture wounds of the foot are discussed in Chapter 46, “Puncture Wounds and Bites.” Lower extremity osteomyelitis is discussed in Chapter 281, “Hip and Knee Pain.”
Normal nail function requires maintenance of a small space between the nail and the lateral nail folds. Ingrown toenails occur when irritation of the tissue surrounding the nail causes overgrowth, obliterating the space.1-3 Causes include improper nail trimming, using sharp tools to clean the nail gutters, tight footwear, rotated digits, and bony deformities.1,3 Curvature of the nail plate is another predisposing factor.3 Symptoms are characterized by inflammation, swelling, or infection of the medial or lateral aspect of the toenail. The great toe is the most commonly affected. In patients with underlying diabetes or arterial insufficiency, cellulitis, ulceration, and necrosis may lead to gangrene if treatment is delayed.
TREATMENT OF INGROWN TOENAILS
If infection or significant granulation is absent at the time of presentation, acceptable treatment is daily elevation of the nail with placement of a wisp of cotton or dental floss between the nail plate and the skin.4 Daily foot soaks and avoidance of pressure on the nail help.4 Another option, if no infection is present, is to remove a small spicule of the nail (Figure 285-1).3 (See Video: Ingrown Toenail Removal.)
Video 285-1: Ingrown Toenail Removal
Used with permission from Alan P. Bocko, Chapel Hill Foot and Ankle Associates; Judith E. Tintinalli, Medical Editor.
Partial toenail removal. This method is used for small nail fold swellings without infection. After antiseptic skin preparation and digital nerve block, an oblique portion of the affected nail is trimmed about one to two thirds of the way back to the posterior nail fold. Use scissors to cut the nail; use forceps to grasp and remove the nail fragment.
A digital nerve block is placed (see Chapter 36, “Local and Regional Anesthesia”). Cleanse the area and prepare the skin for an antiseptic procedure. Trim an oblique portion of the affected nail about one to two thirds of the way back to the posterior nail fold. The nail groove should then be debrided and a nonadherent dressing placed.1,2