Ingrown Toenails Off The Grid

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Ingrown Toenails

In the typical zombie apocalypse movie or TV show, you’ll see gunshot wounds and broken bones. Off the grid, however, minor conditions can be a major detriment to the performance of many activities of daily survival. One of these is the ingrown toenail, also known as Onychocryptosis.

You rugged individualists out there might think toenail problems are no big deal, that is, until you have one. When you have to be at 110% efficiency just to survive, you don’t want to be in pain every time you take a step. In the worst scenarios, ingrown nails can cause skin ulcers, blood infections (also called “septicemia”), or even total loss of circulation (“gangrene”).

Your fingernails and toenails are made up of a protein called keratin. It is the substance that forms the claws (and covering of horns and hooves) of animals. When we refer to issues involving nails, we refer to it as “ungual” (from the latin word for claw: unguis).

 

The nail consists of several parts. They include:

The nail plate: this is the hard covering of the end of your finger or toe; what you consider to be the nail.

The nail bed: the skin directly under the nail plate. Made up of dermis and epidermis just like the rest of your skin, the superficial epidermis moves along with the nail plate as it grows. Vertical grooves attach the superficial epidermis to the deep dermis. In older people, the nail plate thins out and you can see the grooves if you look closely. Blood vessels and nerves run through the nail bed.

The nail (or “germinal”) matrix: the portion or root at the base of the nail under the cuticle that produces new cells for the nail plate. You can see a portion of the matrix in the light half-moon (the “lunula”) visible at the base of the nail plate. This determines the shape and thickness of the nail; a curved matrix produces a curved nail, a flat one produces a flat nail.

An ingrown toenail occurs when the edge of the nail grows downward and into the skin of the toe. It can occur for a number of reasons, but poorly fitting shoes and poorly trimmed toenails are the most common causes. The big toe is usually affected, but any toenail can become ingrown.

Symptoms of an Ingrown Toenail

The skin along the edge of a toenail that is ingrown may appear:

  • Red
  • Swollen
  • Painful
  • Warm to the touch

These are signs not only of pressure on the skin, but also the beginning of an infection. If not treated, the condition worsens, possibly even leading to the drainage of pus.

Ingrown Toenails and Your Shoes

Shoes that are either too tight or too loose can cause ingrown toenails. If too loose, it causes continual pounding of your big toe against the inside due to movement within the shoe as you walk. With shoes that are too small for your foot (or even high heels), extra pressure is placed on your toes which prevents normal nail growth.

Improper Trimming

Nails that are not trimmed properly can also cause ingrown toenails. This happens when your toenails are trimmed too short or you cut your toenails in a rounded fashion instead of straight across. Rounded cuts are appropriate for fingernails, but not toenails. The edges of the nails will tend to curl downward and grow right into the skin.

Other Causes

While the above problems can be rectified, some less avoidable factors like heredity, injuries, or medical conditions may also cause ingrown toenails. Some people are born with nails that are curved and naturally tend to curve inward. Injuries to the nail bed can also cause ingrown toenails, especially if it affects the germinal matrix, the living part of the nail that produces new cells.

People with diabetes or other illnesses that cause poor circulation are also at higher risk for these problems. A diabetic, for example, may experience nerve damage and not realize that excessive pressure is being applied to the toes by ill-fitting shoes. They may not even notice that the nail is growing into the skin.

Badly ignored ingrown nail

Badly ignored ingrown nail

Of course, in normal times, there are doctors like podiatrists or orthopedic specialists you should visit to deal with the problem. Off the grid, however, here’s some tips on how to treat an ingrown nail:

  • Soak the foot in warm water with Epsom salts 3 to 4 times a day. In between soaks, keep the toe dry.
  • Use an antiseptic to decrease the bacterial count in the area
  • Place a small piece of moist cotton, waxed dental floss, or other material  under the nail to help it grow away from the skin.
  • Consider wearing sandals until improved.
conservative management of ingrown nail

conservative management of ingrown toenail

Aggressive Treatment

At some point, you may have no choice but to intervene more aggressively. In these circumstances, you may have to remove the offending segment of nail.

Wedge resection of Ingrown Toenail

Wedge resection of Ingrown Toenail

Take the ingrown curved side, about 1/5 of the nail plate width or less. You may have to cut all the way down to the base in some cases. This procedure is more easily done after injecting some numbing medicine into the area, such as lidocaine. Avoid lidocaine with epinephrine; it may compromise the circulation and possibly lead to gangrene. If you have plain lidocaine, consider establishing a “digital block”, seen below:

After Ingrown Toenail Removal

If the toe is infected, antibiotics might be appropriate. Triple antibiotic ointment may be helpful here, but oral antibiotics, such as Keflex (fish-flex), Clindamycin (Fish-Cin) and Amoxicillin (fish-mox forte) may be necessary.  For more information about antibiotics, go here for the first of a 4 part series.

If a portion of the nail is cut off, patience is required as it will take months for the nail to regrow. If you have a genetic tendency toward ingrown toenails, be prepared to deal with recurrences.

Wearing properly-fitted and protective shoes, managing medical conditions, and teaching appropriate foot grooming methods will make sure that the steps on your journey to medical preparedness won’t be painful ones.

For my youtube video on this topic, click below:

Joe Alton MD

Find out more about ingrown toenails and 150 other medical topics when help is not on the way in “The Survival Medicine Handbook: The Essential Guide for When Medical Help is Not on the Way”, now in its award-winning Third Edition.

Injuries to the Nail Bed

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ingrown-toenail-featured1

 

Minor injuries can sometimes be a major detriment to the function of a member of your survival group. Although perhaps not as life-threatening as a gunshot wound or a fractured thighbone, nail bed injuries are common; they will be more so when we are required to perform carpentry or other duties to which we’re not accustomed.

 

 

Nail Anatomy

 

 

Your fingernails and toenails are made up of protein and a tough substance called keratin. They are, as you can imagine, similar to the claws of animals. When we refer to issues involving nails, we refer to it as “ungual” (from the latin word for claw: unguis).

image#107

The nail consists of several parts:

 

 

The nail plate (body): this is the hard covering of the end of your finger or toe; what you consider to be the nail.

 

 

The nail bed: the skin directly under the nail plate. Made up of dermis and epidermis just like the rest of your skin, the superficial epidermis moves along with the nail plate as it grows. Vertical grooves attach the superficial epidermis to the deep dermis. In older people, the nail plate thins out and you can see the grooves if you look closely. Like all skin, blood vessels and nerves run through the nail bed.

 

 

The nail matrix: the portion or root at the base of the nail under the cuticle that produces new cells for the nail plate. You can see a portion of the matrix in the light half-moon (the “lunula”) visible at the base of the nail plate. This determines the shape and thickness of the nail; a curved matrix produces a curved nail, a flat one produces a flat nail.

torn_fingernail1

In a nail “avulsion”, the nail plate is ripped away by some form of trauma. The nail may be partially or completely gone, or may be lifted up off the nail bed. Ordinarily, depending on the type of trauma, an x-ray would be performed to rule out a fracture of the digit; you won’t have this tool available without modern facilities, but you can do this for an avulsed nail:.

 

 

 

• Clean the nail bed thoroughly with saline solution, if available, and irrigate out any debris. Paint with Betadine (2% Povidone-Iodine solution) or other antiseptic. If you have local anesthesia, you might want to use some; this area is going to be tender.

 

 

• Cover the exposed (and very sensitive) nail bed with a non-adherent (Telfa) dressing. Some add petroleum jelly for additional protection. Change frequently. Avoid ordinary gauze, as it will stick tenaciously and be painful to remove.

 

 

• If the nail plate is hanging on by a thread, remove it by separating it from the skin folds using a small surgical clamp. You can consider placing the avulsed nail plate on the nail bed as a protective covering; it is dead tissue but may be the most comfortable option. Avoid scraping off loose edges, as it may affect the nail bed’s ability to heal.

 

 

• If the nail bed is lacerated, suture it (once cleaned) with the thinnest gauge absorbable suture available (say. 6-0 Vicryl). Be sure to remove any nail plate tissue over the laceration so the suture repair will be complete.

 

 

• Place a fingertip dressing. You might consider immobilizing the digit with a finger splint to protect it from further damage.

 

 

• Begin a course of antibiotics if the nail bed was contaminated with debris.

 

 

In some crush injuries, such as striking the nail plate with a hammer, a bruise (also called an “ecchymosis”) or a collection of blood may form underneath (a “hematoma”). A bruise will be painful, but the pain should subside within an hour or two. A hematoma, however, will continue to be painful even several hours after the event. A bruise will likely appear brownish or blue, but a hematoma may appear a deep blue-black.

nailhematoma

 

For a bruised nail, little needs to be done other than giving oral pain meds, such as Ibuprofen. For a significant hematoma, however, some suggest a further procedure called “trephination”. In this instance, a very fine drill (or a hot 18 gauge needle or paper clip) is used to make a hole in the nail plate. This opening must be large enough to allow blood that has collected under the nail to escape. Once the pressure is relieved, the pain will abate.

 

This procedure should not be performed unless absolutely necessary, as the pain will eventually decrease over time by itself. If you go too deep through the nail, you may further injure the nail bed. The finger must be kept dry, splinted and bandaged for a minimum of 48 hours afterwards.

 

image#136

 

It’s important to know that damage to the base of the nail (the germinal matrix) may be difficult to completely repair, and that future nail growth may be deformed in some way. In situations where modern medical care is available, a hand surgeon is often called in to give the injury the best chance to heal appropriately. Even then, a higher incidence of issues such as “ingrown” nails may occur over time. A completely torn-off nail will take 4-5 months to grow back, maybe more.

 

Joe Alton, MD