Advice for ingrown nail surgery in 11 yr old

Members do not see these Ads. Sign Up.

Hi,

Just wondering. I have an 11 year old with recalcitrant ingrown toe nail. She has a hyperextended IPJ of the 1st toe and wide nail plate.

I have advised nail surgery with phenolisation BUT haven't performed this procedure on someone as young as this before. Just concerned whether this is appropriate at this age - whether we should persevere with rountine nail care until she is older? Is it likely that she will 'grow out of this stage'.


SRD

 

The toe pulp is loaded excessively at toe-off. Suggests hallux limitus or functional limitation of extension at 1st MPJ. Consider a metatarsal bar 1-5.

Any pathological pronation, equinus, 1st ray plantarflexion or metatarsus adductus/primus adductus?

 

Have done PNA successfully on younger. Its not contra indicated. However as alternatives johns idea is a good one. Also if its fibular sulcus a big ole toe wedge below ipj level to keep the 2nd off the 1st can help. Can be all the time but sometimes works if worn just at night. If tibial sulcus then consider the angle of toe off. An orthotic might well help.

Good luck with her.

Robert

 

i'd agree with the above biomechanical intervention, but do the pna with chemical matrixectomy first, i've done plenty on people this age, just ensure they are mature enough to stay relatively still!

 

Would it not make more sense to try the non surgical option first? As you say its quite possible to do NS at this age and younger but its not pleasant.

 

I agree also, from what you say the underlying etiology may be repeated microtrauma.
You can always perform a P&A at a later date, but you can't UNdo it.

Steve

 

possibly, but my view would be that the IGTN is still going to be present, the biomechanics are probably aggravating things. Best to do the pna and then correct the biomechanics. Or a better option would be to do the PNA without matrixectomy to remove the acute problem , then address the pathomechanics. IMO obviously.

George

 

Hi George,

I have no wish whatever to disagree, but if pathological gait IS causing the IGTN, then correction of the pathological gait will cause the IGTN to disappear. The IGTN will NOT still be present if gait is the causative factor and is corrected.

In my opinion, and I believe it to be the only opinion that should be held, we should always as clinicians take the least invasive course first - particularly with young people. Physical scars heal, mental scars are for life!

 

johnpod, i agree. conservative measures should always be sought as an initial intervention, but i don't believe the IGTN will just physically disappear, doing a simple PNA and enabling the nail to grow back will rid unwanted acute stages of the problem whilst giving time for the mechanics to be altered, hopefully stopping the IGTN from re-occuring ( if it is only a mechanical aetiology)

 

Better than a toe wedge, make up an Otoform insert, children love these and will be more likely to use it. Also there is less a possibility for the insert to put pressure on the outside of the said toe.

 

Hey Karen.

Crossed wires. An otroform IS a toe wedge. I meant anything which goes between 1 and two and stops at ipj level.

What did you have in mind as a toe wedge?

And john is, in my experience correct. I have many times seen igtn's resolve with wedges or orthotics without need for surgery. Obviously if there is a huge great spike that needs ito come out but if it is simply a rough edge or corner it can be easily done.

Robert

 

Thanks to ALL,
Just love the arena - it's so great to get input from collegues! It gives me so much more confidence in presenting infromation/alternatives to patients.

There are biomechanical issues with 1st stage HAV and a plantar flexed first ray. Am trying orthotic therapy -have decided to try alternatives to surgery first.

SRD

 

Hi Robert, Sorry but 'Big ole toe' wedge sounded anything but a delicate Otoform divider!
but yes your right.
Karen.

 

As always, it's horses for courses. You are on the spot, so you know whether there is a true functional hallux limitus, or whether it's simply a matter of a tight TEHL. If that's the case then it's probably familial and because of this and the wide nail plate the pathology is unlikely to resolve with mechanical treatment. If the kid is mature and self possessed (and many are these days at 11 yrs.), then go ahead and do the surgery. I suggest Granny will be a better companion than mum - grannys are usually tougher! If the patient is immature, then refer to a colleague who as hospital privileges and can do the job under G.A.

Let us know how things turn out.

All the best

Bill

 

How about "big ole delicate otoform divider"

Joking aside if its an active fibular OC and therefor extremely painful i tend not to be all that delicate, at least initially! Once its settled i might use something with more finesse.

And Bill, of course, is quite correct. It depends on how mature / tough the child is. Good advice on the tough old granny front also, i'll remember that one.

Regards
Robert