Nail Disorders

All or a por­tion of the nail plate can be dam­aged when the feet are injured or abused. Nail prob­lems are com­mon­ly caused by improp­er trim­ming, minor injuries or repeat­ed trau­ma. Some nail dis­or­ders can also be con­gen­i­tal. Prop­er trim­ming (along the con­tour) on a reg­u­lar basis can help keep the toe­nails in the pink, as can wear­ing well-fit­ted, low to mod­er­ate­ly heeled shoes.

Ingrown Nail

Painful ingrown nails may be con­gen­i­tal, caused by an over cur­va­ture of the nail, or an imbal­ance between the width of the nail plate and the nail bed. Toe injuries that change the nail’s con­tour also can lead to an ingrown toe­nail. Toe defor­mi­ties (such as a bunion that forces the big toe to lean toward the sec­ond toe), high-heeled or nar­row, point­ed shoes can put pres­sure between the nail and soft tis­sues, even­tu­al­ly forc­ing the nail to grow into the skin.

Ingrown Nail Symptoms

Red­ness, swelling and infec­tion make the toe very painful. Ingrown nails can be accom­pa­nied by oth­er toe dis­or­ders, such as excess sur­round­ing tis­sue or an out­growth of bone beneath the nail.

Treat­ments for the Ingrown Nail

Surgery is often nec­es­sary to ease the pain and remove the offend­ing nail. Only a por­tion of the nail may be removed. If the entire nail is affect­ed or there is a severe nail defor­mi­ty, the nail plate and matrix (the cells that grow the nail) may be com­plete­ly removed (see ​“Sur­gi­cal Treat­ments for Nail Disorders”).

Fun­gal Infections

Var­i­ous types of fun­gi are present every­where in the envi­ron­ment. The dark, moist sur­round­ings cre­at­ed by shoes and stock­ings make the feet espe­cial­ly sus­cep­ti­ble to fun­gal infec­tion. Most fun­gi are harm­less until they pen­e­trate the skin.

A fun­gus can invade through minor cuts, or after injury or repeat­ed irri­ta­tion to the toes have caused the nail to sep­a­rate from the bed. Fun­gal infec­tions of the nail plate and nail matrix are quite common.

Fun­gal Infec­tion Symptoms

Fun­gus may cause the nail to thick­en and become yel­low or brown­ish. As the fun­gus grows, foul-smelling, moist debris can be seen. Pres­sure from a thick­ened nail or the build-up of debris may make the toe painful.

Treat­ments for Fun­gal Infections

Treat­ment is best begun at the ear­ly stages of infec­tion. The accu­mu­la­tion of debris under the nail plate can lead to an ingrown nail, or to a more seri­ous bac­te­r­i­al infec­tion that can spread beyond the foot. To reduce pain asso­ci­at­ed with a thick­ened, infect­ed nail, the sur­geon may reduce its thick­ness by fil­ing the nail plate down with a sur­gi­cal burr. Fil­ing will not, how­ev­er, pre­vent the infec­tion from spreading.

Oral and top­i­cal med­ica­tions for fun­gal infec­tions may be pre­scribed when:

• Only a small por­tion of one nail is infected
• Sev­er­al nails are affected
• Keep­ing the nail is desired

Med­ica­tion may or may not com­plete­ly elim­i­nate the fun­gus. Often, after med­ica­tion is dis­con­tin­ued, the fun­gus recurs. Your podi­atric foot and ankle sur­geon will mon­i­tor the results of oral pre­scrip­tions care­ful­ly and will explain any pos­si­ble side effects. While top­i­cal oint­ments usu­al­ly do not elim­i­nate the fun­gus, they may be effec­tive when used direct­ly on the nail bed, after the nail plate has been removed. Elim­i­nat­ing the infec­tion, in some cas­es, can only be achieved by per­ma­nent removal of the nail plate (see ​“Sur­gi­cal Treat­ments for Nail Disorders”).

Blood Beneath the Nail (hematoma)

A very com­mon result of active lifestyles is blood, or a hematoma, beneath the toe­nail. Hematomas are espe­cial­ly com­mon among peo­ple who jog or play ten­nis, caused by the toes repeat­ed­ly rub­bing against the shoe. A hematoma might indi­cate a frac­tured bone, espe­cial­ly after an injury (such as drop­ping a heavy object on the end of the toe). The toe should be exam­ined by the podi­atric foot and ankle sur­geon, who may take an X‑ray to deter­mine the most appro­pri­ate treatment.

Hematoma Treat­ments

If the hematoma is treat­ed with­in the first few hours of form­ing, the podi­atric foot and ankle sur­geon will cre­ate a tiny hole in the nail plate using a fine-point drill or scalpel. This releas­es the blood and relieves pain. If sev­er­al days have passed and the blood clot becomes painful, the nail plate may require removal so that the nail bed can be cleaned. Some podi­atric foot and ankle sur­geons pre­fer to remove the nail plate when­ev­er blood forms beneath it, because the blood can attract fun­gi and lead to infec­tion. The nail may also be removed to treat a bone frac­ture beneath the hematoma. If the bone has frac­tured but has not moved out of its nor­mal posi­tion, a splint may be used to keep the toe aligned dur­ing heal­ing. Nail plates that have been removed will grow again with­in three to six months.

Sur­gi­cal Treat­ments for Nail Disorders

If the prob­lem is severe or chron­ic, surgery to remove all or a por­tion of the nail may be rec­om­mend­ed. Most surg­eries are per­formed very com­fort­ably under local anes­the­sia and require less than one hour at the podi­atric foot and ankle sur­geon’s office. Laser surgery, because it requires spe­cial equip­ment, may be per­formed at a hos­pi­tal. While these are some of the most com­mon­ly pre­scribed treat­ments for nail dis­or­ders, oth­ers may be used. The podi­atric foot and ankle sur­geon will deter­mine which treat­ment is like­ly to be the most suc­cess­ful in each case.

Par­tial Nail Removal

For some cas­es of ingrown nails, only the por­tion of nail that is grow­ing into the skin is removed. If both sides of the nail are ingrown, they may be removed dur­ing one pro­ce­dure. After the affect­ed por­tion of nail (one-eighth to one-quar­ter inch) is tak­en, the nail bed is removed along with any enlarged tis­sue adja­cent to the nail plate. The nail root and matrix are then destroyed by phe­nol, sur­gi­cal removal or laser heat (see ​“Per­ma­nent Nail Removal”). Final­ly, the skin may be remod­eled around the nail.

Per­ma­nent Nail Removal

Com­plete removal of the nail plate is a com­mon rem­e­dy for fun­gal infec­tions and ingrown nails. Dur­ing this pro­ce­dure, the nail plate is removed and the nail matrix is destroyed by one of three methods:

• Phe­nol — an acidic chem­i­cal called phe­nol is applied only to the nail matrix. This destroys the growth cells of the nail.
• Sur­gi­cal removal — the nail matrix and bed is cut away. Stitch­es are only occa­sion­al­ly necessary.
• Laser - a form of burn­ing in which laser heat is focused on the matrix cells.

Removal of Bone Overgrowth

Bone direct­ly beneath the nail plate may become enlarged, devel­op­ing a spur or out­growth that can deform the nail plate or lead to an ingrown nail. Removal of excess bone may be per­formed con­cur­rent­ly with surgery to par­tial­ly or per­ma­nent­ly remove the nail plate.

Care After Surgery

Most peo­ple expe­ri­ence very lit­tle pain imme­di­ate­ly fol­low­ing nail surgery and dur­ing the heal­ing process, which lasts approx­i­mate­ly two to three weeks. If bone has been removed dur­ing surgery, a longer heal­ing process should be anticipated.

Total Nail Removal /​Partial Nail Removal

The podi­atric foot and ankle sur­geon may pre­scribe med­ica­tion for pain and may, but not always, advise that the toe be soaked two or three times dai­ly for one week. Some amount of drainage is nor­mal when the nail has been removed chem­i­cal­ly or by laser. If the nail has been par­tial­ly removed and stitch­es were used to form a new nail fold, they are removed in approx­i­mate­ly 10 days.

Ingrown Nail

Dai­ly soak­ing in a saline solu­tion may be rec­om­mend­ed. If the toe is inflamed or infect­ed, a top­i­cal antibi­ot­ic is applied for three to sev­en days; if the infec­tion is severe, an oral antibi­ot­ic may be pre­scribed. In very few cas­es, the infec­tion may invade the bone beneath the nail, requir­ing hos­pi­tal­iza­tion and fur­ther treat­ment. The heal­ing process gen­er­al­ly does not inter­fere with dai­ly activities.

Hematoma

Fol­low­ing sim­ple drainage of a hematoma, the podi­atric foot and ankle sur­geon may advise that the toe be soaked and treat­ed with top­i­cal antibiotics.

How Will the Toe Look After Surgery?

After surgery to per­ma­nent­ly remove the nail plate, the body gen­er­ates a hard­ened skin cov­er­ing over the sen­si­tive nail bed. When this cov­er­ing has devel­oped, nor­mal activ­i­ties can be resumed. Women can also use nail pol­ish on this area.

Will the Nail Regrow After Removal?

Par­tial growth of the nail plate after per­ma­nent removal is rare, but pos­si­ble. Because the nail matrix has been destroyed, the nail should not grow again.