Trick of the Trade: Toe paronychia splinting

Ingrown toenails, or paronychias, are usually exquisitely painful and a bit gnarly when they present to you in the Emergency Department. Dr. Stella Yiu described toenail splinting techniques using steristrips or dental floss. The purpose of splinting is to prevent the toenail from growing back into the lateral nail fold.

This assumes a relatively mild-to-moderate case. Often simple elevation of the nail out of the lateral nail fold (under digital block anesthesia) is all that is needed to treat a paronychia. Pus is often released with this maneuver.

What do you do for more severe cases when you have to excise the lateral edge of the nail?

There’s no toenail to slide the steristrip/ cotton/ dental floss material under.

Trick of the Trade

Angiocatheter in nail fold

I have heard of providers wedging a thin roll of cotton into the nail fold to prevent the nail from regrowing into an ingrown toenail again. I find, however, that the cotton absorbs too much moisture day in and day out, while sitting in the nail fold.

Alternatively, you can slide an 18-gauge angiocatheter (just the plastic part) into the potential space. The new nail should then grow over this plastic “splint”. The above photo is of a patient’s toe with a brewing ingrown toenail for over 1 month! Both edges needed to be trimmed down longitudinally. Way to go, med student ST. You know who you are.

The added benefit of the angiocatheter over the cotton is that if you needed to remove it for whatever reason, it’s easier to remove as one piece than cotton.

I got this idea from the concept of a toenail “gutter splint” from this a review article from American Family Physician.

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