Residency Insight -- A PRESENT Podiatry eZine

The Ingrown Toenail

by John Steinberg, DPM
PRESENT Editor
Assistant Professor,
Department of Plastic Surgery
Georgetown University
School of Medicine

Many of you have heard DPMs speak about the pride one can take in the fact that “patients walk in my office with pain and leave without it”. There are certainly many specific examples of this in the typical podiatric practice, but I think none captures it better than a good-old run-of-the-mill ingrown, infected toenail!

There may not be a lot of glamour in treating paronychia, but there sure is a lot of patient satisfaction. This pathology presents in patients of all ages, shapes, and sizes. Many of these persons have already tried lots of home remedies, ‘bathroom surgery’, and have been to other healthcare practitioner’s offices or even the local emergency room.

My favorite part is the injection, especially in those patients who have had attempted blocks by another specialty. They are petrified that you are going to stick the needle into the distal pulp of their toe and that you are going to use a 12 gauge needle suited for a horse. Now, I’m not saying these injections are painless, but it is always great to hear “that was not so bad” or “that sure was better than when they tried in the ER”.

A recent case that I encountered was a paronychia in a healthy 22 year old female. She was a Peace Corps member and was urgently airlifted from her post overseas, due to an ‘atypical infection of the great toe with possible osteomyelitis or mycobacterium’. This infection had been persistent for 5 months and had not responded to 3 prior attempted ingrown toenail removals overseas and numerous antibiotics. A direct inpatient admission was arranged and she was already placed on IV antibiotics when we were consulted. There was some question raised of bone erosion to the distal phalanx and we were asked to do a bone biopsy. On review of the x-rays and MRI, I disagreed with the osteomyelitis concern and instead we did a simple partial nail avulsion at the bedside. We found a very typical ingrown nail spicule that remained under the proximal nail fold. She had immediate relief and resolution of her symptoms with discharge from the hospital the next day!

Podiatric Medicine has evolved very well over the recent decades and we have taken an increased leadership role in research, surgical techniques, and medical treatments. There are many parts of our profession that some would like to leave as part of the past. While I understand the increased interest in our surgical sub-specialties, I think medicine needs to remain part of Podiatry. Onychomycosis and verruca plantaris may not be part of your future practice, but there should be a colleague that you can refer that patient to with a DPM behind his / her name. There are many facets to our profession and each one of them can play a role in what you choose to do with your day. Good luck at finding your part of Podiatry!

J Steinberg signature
John Steinberg, DPM
PRESENT Editor
Assistant Professor,
Department of Plastic Surgery
Georgetown University School of Medicine
[email protected]