Introduction
This case study concerns Mr. X, who presented at the podiatry clinic with Onychocryptosis (or ingrown toenails). I have consent and confidentiality from him to use his medical records for further clinical learning (Appendix 3). This case study will discuss the presenting complaint of Mr. X, assessment carried out with the justification, and management plan.
Relevant medical conditions
Mr. X is healthy. He didn’t have significant medical history except 2 weeks before presentation; he visited a general practitioner (GP) for pain and swelling of left foot toes that was diagnosed as cellulitis. Cellulitis is a common noncontagious bacterial infection that affects skin and subcutaneous tissue. It is caused by a breach of skin, allowing invasion of bacteria to deep skin layers, and presents with local pain, swelling, erythema, and warmth (Raff and Kroshinsky, 2016). The GP gave Mr. X antibiotics to treat cellulitis. \
Presenting Complaint
Mr. X presented with pain, swelling, and erythema of the lateral sulcus of left hallux that were more severe days ago and now subsided after receiving antibiotics. On examination, he had an ingrown toenail of left hallux with minimal edema and granulation tissue [figure 1]. Ingrown toenail (or onychocryptosis) is a common painful foot condition characterized by growing of nail edge into the surrounding paronychium resulting in a cascade inflammation, pain, infection, and reparative processes (Khunger and Kandhari, 2012). Onychocryptosis mainly affects the great toenail, commonly the lateral side (Singh and Kumar, 2016). Patients with ingrown nails often present with foot pain, edema, suppuration and difficulty in walking. The affected nail usually gets infected and symptoms worsen (Khunger and Kandhari, 2012).
Assessment, findings, and indications
Before deciding a treatment plan, Mr. X’s lower extremities were examined to rule out underlying disease particularly neuropathy, vascular problems, or other dermatological disorders (Reyzelman et al., 2000; Saral et al., 2013; Levy, 2015).
Vascular Assessment
Mr. X dorsalis pedis and posterior tibial pulsations were normal, and the Doppler ultrasound on both lower extremities showed normal triphasic pulses. Skin color and temperature were normal. Were vascular abnormalities suspected, a vascular surgeon must be consulted before next step of management (Levy, 2015). Patients with vascular diseases have a poor healing capacity making the ingrown nail very susceptible to secondary infection (Haneke, 2012).
Neurological Assessment
Mr. X’s neurological examination revealed normal peripheral sensations (he scored 11/11 on the 10g monofilament in both feet). Neurological examination in patients with ingrown nail rules out neurological disorders [e.g. peripheral neuropathy] that may increase the risk for ingrown nail because of diminished sensation and altered gait making feet prone to repetitive trauma (Saral et al., 2013).
Dermatological
Mr. X’s skin was normal. Only mild inflammation and minimal granulation tissue were noted at the lateral sulcus of left hallux. Any local infection should be treated to avoid inactivation of the local anesthetic agent if nail surgery was decided (Reyzelman et al., 2000; Ueno et al., 2008). Infections create an acidic medium that makes the anesthetic agents (e.g. lidocaine) used to numb the patient infective (Ueno et al., 2008).
Footwear Assessment
Mr. X wore a pair of new trainers with narrow toe box. Wearing tight shoes is a risk factor for ingrown nail and secondary infection. If shoes are too tight, toes will jam into the end of shoes, putting nails at high pressure and exposing them to repetitive trauma (Haneke, 2012). Shoes should be approximately a thumb width longer than the longest toe to allow a space for feet to move inside shoes particularly during running or high impact exercises. The width of shoes is equally important (Erdogan et al., 2012; Rauch and Cherkaoui-Rbati, 2014).
Ingrown nail Assessment
Ingrown nail examination is essential for proper classification and subsequently appropriate management (Heidelbaugh and Lee, 2009). There are five stages of ingrown nail [table 1] (Kline, DPM, 2008).
Short term treatment plan
At stage II, Mr. X was indicated for nail surgery. Stage II ingrown nail is best treated with partial nail avulsion which comprises removal of minimum amount of nail required for ingrown nails to be resolved effectively (Richert, 2012; NHS, 2015). However, using partial nail avulsion alone is successful in 30% of cases and recurrence rate is high (Bos et al., 2007). Therefore, phenolization (or local injection of phenol) is recommended after partial nail avulsion for destruction of nail matrix that may result in recurrence (Andreassi et al., 2004; Singh et al., 2016). Before surgery, Mr. X was examined to have no vascular or neurological problems that may increase infection risk postoperatively (Levy, 2015). However, he had residual left hallux infection, and the antibiotic course was decided to be completed. Mr. X was advised to clean the wound with saline and to soak it in warm water to help reduce the inflammation (Joel J. and Lee, 2009).
Preoperatively, Mr. X signed a written consent stating he was informed about the benefits, risks, and alternatives of the procedure. A sterile environment was prepared. All equipment utilized were sterile (Appendix 4). Mr. X lied in supine position with feet hanging off the edge of the table. His left foot was initially cleansed with iodine, then alcohol was applied. A dose of 2.2 ml (maximum dose 3.3ml) of plain mepivacaine 3% was injected at various sites of the big toe for anesthesia (NHS, 2015). For Mepivacaine inhibits impulse initiation and neural transmission through temporary blockage of sodium channels. Blockage of sodium channels results in inhibition of sodium influx, membrane depolarization, and subsequent temporary loss of sensation (Leffler et al., 2010). A prick monoto test using a neurotip was performed to ensure patient doesn’t feel pain. If patient reported pain, toe massage is performed and extra doses of mepivacaine are provided (maximum 6 mg/kg) ( NHS, 2015). Mr. X didn’t show any signs of allergy to the anesthetic agent (appendix 5) ( NHS, 2015).
After anesthesia, a sterile toe tourniquet was tied proximally around the big toe for hemostasis, and the lateral 20% of the nail was identified for excision. A nail elevator was then used to separate this lateral part of the nail from its nail bed to prepare it for excision. Being elevated, the nail was cut from the distal end straight backwards, and the cut part was twisted and removed. Removal of all fragments of the lateral nail was confirmed to minimize recurrence (Heidelbaugh and Lee, 2009). The tourniquet was removed after 8 minutes to allow blood flow. Tourniquet should be applied for the shortest time possible to avoid distal toe ischemia, necrosis and gangrene (Karabali et al., 2005). After that, phenol was applied to the nail fold to destroy the nail-forming matrix.
For wound care, many types of dressings are available for use after nail surgery. The most common three types are demonstrated in table 2. Patients undergoing local nail surgery operation must be examined to ensure there’s no history of allergy to any types of dressings, tapes, or local anesthetic agents. Mr. X didn't show any signs of allergy to the anesthetic agent. To ensure a patient would not develop any allergic reaction, a skin test is performed with a low dose of the anesthetic agent prior to the full dose of anesthesia (NHS,2015).
For the best outcome, a non-adherent dressing incorporating a bactericidal agent is recommended. If the patient is allergic to any bandage incorporated-medications, that bandage should be avoided. Mr X. had no allergies; therefore, Bactigras dressing was used.
Long-Term treatment Plan
Postoperatively, Mr. X was informed that the toe may be numb after the procedure, but the sensation and pain will return 2 hours after the anesthesia wears off (Crincoli et al., 2015). For pain relief, non-aspirin analgesics were advised. Aspirin should be avoided because it increases the risk of bleeding (Zuber, 2002). He was also educated about foot wear, nail trimming, foot hygiene, and avoiding trauma.
Mr. X was instructed to have his first follow-up visit 24 hours postoperatively to reassess the wound and remove and redress the dressing. The second and third visits were scheduled after 1 and 2 weeks, respectively (Al-Lenjawi et al., 2018). In certain cases, re-dressing may be required 7 days postoperatively if complication occurred (NHS, 2015). The healing time depends on many factors including the patient's age, co-morbidities, concomitant medications used, and bleeding diathesis (Karaca and Dereli, 2012). Young healthy individuals – like Mr. X – often heal within a week. Elderly patients with multiple medical co-morbidities may need a few weeks to heal (Gould et al., 2015).
Conclusion
In conclusion, managing a patient with infected ingrown toenail requires assessment across several areas, and if necessary, treated with nail surgery. Despite being a simple condition, meticulous care is needed to ensure that infection heals completely. Finally, effective patient educations combined with proper healthcare management are required to optimize treatment of ingrown nail infections.
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