Abstract
Corresponding Author(s)
Scott Klosterman, DO, Assistant Professor of Family Medicine, Spartanburg Regional Family Medicine Residency Pro- gram, 853 N. Church St., Suite 510, Spartanburg, SC 29303.
E-mail address: sklosterman@srhs.com.
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Family physicians are often the primary health care con- tact for patients with toenail problems. Toenail complaints ranging from paronychia to onychomycosis affect every age group, and surgical excision of the nail may be an appro- priate treatment option. Our purpose is to review the indi- cations and procedural details for toenail removal, provide a concise patient consent form and educational handout for postprocedural care, and review the current International Classification of Diseases, 9th revision (ICD-9) and current procedural terminology (CPT) coding for such procedures. In addition, multiple authoritative references are provided to include an internet-based video demonstrating the basic components of this procedure.1-6
Indications
Nail removal is an appropriate office-based procedure for many acute and chronic toenail conditions treated by family physicians.1-6 Some of these acute conditions, such as nail trauma and ingrown toenails (onychocryptosis), may require partial or full nail plate removal. In addition, recurrent paro- nychia, onychomycosis, and onychogryphosis (nail deformi- ties that cause pain) constitute chronic ailments that may ne- cessitate toenail removal when response to conservative medical management has failed.7-10 After removal of the nail, a partial or complete matrixectomy (permanent nail removal) may be necessary for these chronic conditions, and with on- ychocryptosis because of its high rate of recurrence.2,4,11 Fi- nally, in cases of growths or discoloration beneath the nail, nail plate removal with biopsy may be needed to rule out malignant neoplasms, although biopsy techniques of the nail and nail bed are outside the scope of this review.2,3
Contraindications/complications
Caution should be used in patients with peripheral vascular disease, diabetes mellitus, collagen vascular diseases, or other immune compromised states. Procedural complica- tions include laceration of the nail bed, infection and para- sthesias postoperatively, and failure of matrixectomy lead- ing to regrowth of the nail.1-5
Materials
Absorbant drape/pad
Sterile and nonsterile gloves
5-7 mL of local anesthetic (1% lidocaine without epi- nephrine) and a 23–25-gauge needle
Alcohol wipes
Betadine or chlorhexidine topical solution
Large and small cotton-tipped swabs
Rubber band or other tourniquet
Straight hemostat or periosteal elevator
Nail splitter (if performing partial nail removal)
Scissors
Electrocautery or silver nitrite applicators
Phenol 85-88% and petroleum jelly (if performing ma- trixectomy)
Saline solution
4 X 4-inch gauze
Antibiotic ointment
Surgical tape
Procedure1-6
Consent
Obtain written consent for the procedure from the patient or legal guardian, using the consent form example pro- vided in the Appendix.
Preparation of the above listed materials should be avail- able in the procedure room and can provide for an ap- propriate “timeout” for the patient procedure.
Digital nerve block (three-sided)
Have the patient lie supine on the examination table with knees flexed. The affected foot should be placed flat on the examination table over an absorbent drape or pad.
Cleanse the distal portion of the metatarsophalangeal (MTP) joint with an alcohol wipe or sterilizing solution at the injection locations mentioned below.
Hold the needle perpendicular to the toe and place it distal to the MTP joint on the medial aspect of the digit (Fig. 1).
After aspirating for blood, slowly inject 1-2 mL of an- esthetic while slowly advancing the needle toward the plantar surface until a wheal of the anesthetic medicine is seen on the plantar aspect of the digit.
Without removing the needle completely, redirect it across the dorsal aspect of the toe. Administer anesthetic while directing the needle laterally. A total of 2 mL is sufficient (Fig. 2).
Remove the needle completely and replace where the wheal of anesthetic is present on the lateral aspect of the toe, distal to the MTP joint (Fig. 3).
Repeat step 4 above.
This digital nerve block can be adapted to perform a four-sided (ring) block by performing the procedure above with one additional step. After performing the three-sided block, remove the needle completely. Repo- sition the needle to the plantar surface of the toe medially and slightly distal to the MTP joint. Administer 1 mL of anesthetic while the needle is advanced laterally.
Nail avulsion
After sufficient anesthesia is achieved, a rubber band may be used to minimize bleeding by cinching it tight around the base of the toe with a pair of hemostats. A tourniquet wrapped from the nail to the base of the MTP can be used as an alternative.
Wearing nonsterile gloves, prep the toe with sterilizing solution using large cotton-tipped applicators or 4 X 4-inch gauze. Start at the center and work outward, covering the entire digit. Repeat three times.
Apply sterile gloves and stabilize the affected toe with your nondominant hand.
Slide the tip of a hemostat or periosteal elevator under the distal edge of the nail plate. Advance proximally parallel to the nail while applying gentle pressure. Force should be applied proximally and superiorly to minimize damage to the nail bed (Fig. 4).
Continue to work proximally to loosen the nail plate from the nail bed until you reach approximately 0.5 cm past the cuticle. Repeat this procedure under the adjacent areas until you have freed the entire width of the nail plate.
Grasping the lateral edge of the nail, use a twisting motion to free the nail plate from the lateral fold. Repeat on the other side.
Push back the cuticle to free the proximal nail fold along the entire width of the nail. A blade or scissors may be needed for this step.
Insert the hemostat or periosteal elevator under the entire surface of the nail plate to ensure that all soft tissue attachments are loosened prior to attempting to remove the nail (Fig. 5).
Grasp the distal nail plate lateral to the midline with the hemostat. Administer a steady pull with a twisting force medially. You will feel the nail plate free from under the cuticle. If needed, move to the medial side and repeat the motion laterally.
After the nail plate is removed, clean any loose epithe- lial tissue remaining on the nail bed with a pair of sharp scissors. Stop any bleeding of the nail bed using elec- trocautery or silver nitrate applicators (Fig. 6).
This procedure may be adapted for partial avulsion by simply removing the affected portion of the nail plate. Separate the affected portion (typically one-third of the entire nail) from the nail bed and lateral fold as described above. Advance a nail splitter down the length of the nail to the cuticle, then cut. Remove the avulsed nail plate with hemostats, leaving the unaffected nail intact.
Matrixectomy
If the patient desires permanent nail ablation, a chemical ma- trixectomy should be performed after nail avulsion as follows:
Coat the lateral nail folds with petroleum jelly to prevent unwanted damage during phenol treatment. Also, ensure excellent hemostasis with electrocautery or silver nitrate applicators as above because of the inactivation of phe- nol by blood.
Apply phenol-soaked small cotton swabs to the nail bed at the cuticle and hold in place for 60 seconds. The matrix will turn gray-white. Repeat across the entire nail bed and under both lateral nail folds (Figs. 7 and 8).
Remove the rubber band or tourniquet.
Irrigate the area with isopropyl alcohol or saline solution to neutralize the phenol.
Post-procedural care
Apply antibiotic ointment to the entire nail bed. Cover with folded 4 X 4-inch gauze, wrap toe with roll gauze, and secure with surgical tape.
Provide the patient with a medication for pain relief for at least the first 48 hours post procedure (ibuprofen or acetaminophen are typically sufficient), as well as the patient handout provided in this article for home care.
Paronychia, toe (681.11)
CPT codes13
Nail removal, partial or complete (11730) Permanent nail removal, partial or complete
(matrixectomy) (11750) Biopsy of nail unit (plate,
bed, matrix, hyponychia, etc.) (11755)
Onychocryptosis (703.0)
Toe neoplasm, primary malignant (195.5)
Finger neoplasm, primary malignant (195.4)
Toe or finger neoplasm, benign (229.8)
Toe or finger neoplasm, uncertain behavior (238.8)
Coding and billing
Current diagnostic ICD-9 and CPT codes are provided (see Table 1) to allow the physician to accurately document the patient’s indication for toenail removal and bill for this service.
References
Lawrence C: An Introduction to Dermatological Surgery, 2nd ed. London: Churchill Livingstone, 2002
de Berker DAR, Baran R, Dawber RPR: Handbook of Diseases of the Nails and their Management. Oxford: Blackwell Science, 1995
de Berker D, Baran R, Dawber R: Disorders of nails. In Burns T, Breathnach S, Cox N, et al (eds.): Rook’s Textbook of Dermatology, 7th ed. Oxford: Blackwell Science, 2005
Zuber T: Ingrown toenail removal. Am Fam Physician 65:2547-2550, 2002
Pfenninger J, Fowler G: Procedures for Primary Care. St. Louis: Mosby, 2003
Schraga E, Kulkari R: Ingrown toenail removal. Nov 10, 2009. Link http://emedicine.medscape.com/clinical_procedures#softtissue. [Click on “Ingrown Toenail Removal” and then “View Multimedia Library” for a series of videos demonstrating the procedure]
Rigopoulos D, Larios G, Gregoriou S, et al: Acute and chronic paro- nychia. Am Fam Physician 77:339-346, 2008
de Berker D: Fungal nail disease. N Engl J Med 360:2108-2116, 2009
Bednar MS, Lane LB: Eponychial marsupialization and nail removal for surgical treatment of chronic paronychia. J Hand Surg (Am) 16: 314-317, 1991
Grover C, Bansal S, Nanda S, et al: En bloc excision of proximal nail fold for treatment of chronic paronychia. Dermatol Surg 32:393-398, 2006
Rounding C, Bloomfield S: Surgical treatments for ingrowing toenails. Cochrane Database Syst Rev (2):CD001541, 2005
Hart A, Stegman M, Ford B (eds.): International Classification of Diseases, 9th rev. Eden Prairie, MN: Ingenix, 2010
Gabbert W, Kachur K, Canter K (eds.): The 2011 Current Procedural Coding Expert. Eden Prairie, MN: Ingenix, 2010
Appendix
Patient handout: toenail removal
What do I do after the procedure?
Wear an open-toed shoe home from the procedure and for the next several days.
Have a family member or friend drive you home after the procedure.
Try to elevate your foot and rest for the first 24 hours.
Use a cloth-covered ice pack as needed for pain. Keep it in place for no longer than 20 minutes without a break.
Take pain medication as instructed by your doctor for at least the first 24 hours.
After the first 24 hours, wash the toe with soap and warm water 1-4 times daily for at least 5 days after the procedure.
You may return to normal activities in 48 hours, but do not perform strenuous exercise for at least one week.
Change your dressing daily until fully healed. Soak the toe in warm water to help remove the gauze. Apply a small amount of antibiotic ointment to the nail bed, and then cover with a clean gauze.
What are the possible complications?
Pain and swelling
Infection
Bleeding
Deformity of the nail if it grows back
Numbness or tingling in the affected toe When should I call my doctor?
Persistent or increasing pain, redness or swelling of the toe after 24 hours
Pus formation
Persistent or excessive bleeding
Fever or chills
Unwanted regrowth of the nail
How do I avoid toenail problems in the future?
Avoid trauma to the nail from pedicures or from poorly-fitting shoes
Avoid prolonged exposure to irritants such as water and nail polish,
Frequently change sweaty socks and shoes.
Cut the nail flat across the entire length and don’t share nail clippers (see Figure 9 below).
Figure 9 Correct nail cutting technique. Cut the nail so that the corners of the nail protrude beyond the nail folds (flat across the length of the nail).
Consent for medical procedure: toenail removal
Name of Patient: Date of Birth:
I authorize and direct Doctor(s) and/or such assistants as may be selected by him/her to perform the following procedure upon me: Partial/Total Toenail Removal with or without Matrixectomy.
The indicated procedure will be performed on my Left/Right toe.
Description of operation in layman’s terms: Removal of deformed or ingrown nail with or without chemical treatment to prevent nail regrowth. An anesthetic medicine will be injected within the toe to provide pain control.
Dr. has explained to me my condition, the procedure and its potential risks and complications. These complications include: Bleeding, infection, numbness or tingling to the affected toe, laceration to the nail bed, deformity of the regrown nail, and regrowth of the nail (if matrixectomy is performed).
No guarantee or assurance has been made as to the results that may be obtained and he/she has advised me of alternative therapies and has answered my questions.
I, the undersigned, have read and fully understand this consent form and it has been explained to me, to my satisfaction.
Patient Signature Date and Time
Person Authorized to Sign for Patient Relationship Signature of Physician Obtaining Consent Physician Name Witness Signature Witness Name