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Poor nail cutting leading to sunken nail and fleshy/tighly compacted sulci

Discussion in 'General Issues and Discussion Forum' started by lucyjones79, May 24, 2011.

  1. lucyjones79

    lucyjones79 Welcome New Poster

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    I have recently been to a patient for what was routine nail cutting, and callus debridement.

    The right hallux nail had been cut back very far and as a result the nail was way too short, and had 'sunken' into the sulci which had made the gap between the nail and sulci very tight, thus causing discomfort to the patient.

    I cleared out both sulci with a blacks file, and packed the area as best I could with cotton wool to try and elevate the nail from the bed/sulci, to enable it to grow up away from the edge of the digit, and this prevent it from leading to cryptosis.

    I saw the patient a few weeks later and the cotton wool packing had come out, and there was a small pocket of pus in the area as the nail was digging into the sulci.

    As a result I cut the nail back, and took a small section, and it provided great relief to the patient. I packed the area with inadine, and when I saw the patient again there was no immediate problem with any digging of nail edge into the sulci.

    The main problem I have now is encouraging the nail to grow up over the free edge of the digit, to prevent further problems occurring.

    Does anyone have any advice regarding how to do this? I have packed the area with cotton wool, but am concerned that the cotton wool is going to continue to fall out between visits, and the nail is going to dig in repeatedly, thus leading to a further section and a vicious circle?

    The nail does appear to be very wide and have discussed possible PNA with patient but she does not seem very keen, and I would have to refer her on for this.

    Any advice would be very much appreciated!! It may seem simple but its causing me a headache!:bang:

    Many Thanks.
  2. G Flanagan

    G Flanagan Active Member

    Lucy, I must say I prefer to take the more logical step and just do a PNA.

    You mention the patient isn't keen, but would they prefer a procedure that once done and successful would mean that they are cured. Or do they want a bit of cotton wool, a sprinkle of fairy dust and a magic wand which would probably mean they have to keep coming back.

    I know there are a large number of people who would take the latter approach, but in the words of Gordon Ramsey, PNA DONE. :deadhorse:
  3. Catfoot

    Catfoot Well-Known Member

    I am just curious as to what your training taught you to do in these situations ? :confused:


  4. lucyjones79

    lucyjones79 Welcome New Poster


    I agree. I stressed the need to contact one of my colleagues who can carry out a pna, so am hoping that the patient takes my advice.

    Thanks for your advice!


    During study I didn't really come across a very tightly compacted nail, that was due to poor nail cutting, but came across many involuted nails and we were told to pack the area with cotton wool, or a clear gel which ''set'' in situ (Cant remember the name) but it was also used in dental settings.
  5. heathpod

    heathpod Welcome New Poster

    Hi Lucy,
    Have you looked at the possiblility of bracing the nail? There are plastic ones available that do give quite good relief for the patient while the nail grows out, as long as they are correctly fitted. You can find them in the Canonbury catalogue, I think.
    I would also be looking at their footwear, to see if a change might give them some relief. However, if the nail is just too wide a PNA might be the only solition.

    Good luck!
  6. MicW

    MicW Active Member


    Just a late addition to your problem. With regards to keeping the packing in - if the patient has no vascular compromise, and the wound is neither infected or inflamed - I use silicon to hold the packing in (basic roof and gutter silicon).

    It works very well and depending on the activity level of the patient can remain in place for months.

    Warning - if the above criteria are not considered you could seal off an abcess.

    Also, if using this method, dust the silicon with powder before allowing the patient to put their socks back on.
  7. G Flanagan

    G Flanagan Active Member

    MicW, it seems on this post I am just heckling at the treatments offered by some Pod's and by far my treatments are not the gold standard HOWEVER your post regarding using roof & gutter silicone. I can't actually tell if your being serious or not. Not medical grade silicone (which has its own problems anyway) but roof & guter silicone, why not sprinkle a tad of asbestos under their nose while your at it. Surely you don't apply this to your patients. The MHRA and lawyers would have a field day. Where did you learn this technique? or is there some recent EBM thats shows its worth?
  8. cornmerchant

    cornmerchant Well-Known Member

    Trying to separate one bit of rubbish from another on this thread.

    Nails don't 'sink' , so that may be just a poor description on your part Lucy , it may be the case that the nail has been cut inappropriately, but tight nail folds do not necessarily mean that PNA is required. I have never packed a nail in 17 years, nor would I bother with a nail brace.
    Careful monitoring of the nail until it is at a good length to see both free edges, without any intervention ,will mean that future care of the nail will be straight forward.
    Surgery is indicated if there has been more than one episode of true onycocryptosis, but most cases are self inflicted or by an unqualified provider, and will respond well to palliative care.

    Do refer to someone that has more experience Lucy , and maybe learn from this.

  9. MicW

    MicW Active Member

    G Flanagan,

    Of course I'm serious. I've been using this for around 20 years and was shown by another senior Podiatrist.

    Feet cannot read textbooks.
  10. G Flanagan

    G Flanagan Active Member


    if, for example, a patient had a reaction to your gutter silicone treatment and decided to seek legal advice how would you justify your treatment regime.

    Im playing devils advocate I know, but it could happen.

  11. Steve_Pod

    Steve_Pod Member

    Hi Lucy,

    As long as the skin in the sulcus is intact with no discharge, you can keep packing and repacking the cotton wool. I use a very small amount of Friar's Balsam (Tincture of Benzoin Compound) and this helps the cotton wool to stay in place. You can pack and repack the sulcus weekly or bi-weekly. Initially, the patient doesn't like returning so frequently but within a month or two, the nail has grow out of the sulcus and beyond the skin.
  12. Catfoot

    Catfoot Well-Known Member

    Hello StevePod,
    I am curious.
    Where was it you learned this procedure that requires that the patient attend the surgery weekly, or bi-weekly?


  13. cornmerchant

    cornmerchant Well-Known Member

    This is becoming a case of the blind leading the blind.
  14. brekin

    brekin Active Member

    Chances are that the client will end up with a PNA anyway. If not from this event then within a couple of years.

    Conservatively all you can really try is to use the Black's file to file as slight an incline down the lateral aspect of the nails so there is no sharp "corner" to dig in as the nail grows out. Probably monthly appointments until resolved. Some packing can help but only if lateral aspect of nail properly shaped.

    But I would make it known to the client that, even if it resolved, there is a liklihood of reoccurrence.

  15. RobinP

    RobinP Well-Known Member

    You know what they say about cats and curiosty;) and that's just twice on this thread!
  16. Steve_Pod

    Steve_Pod Member

    I learned this from feedback from patients.Sometimes they complained of pain a week or two after the initial application of the cotton wool and Friar's Balsam.

    If the nail was deeply embedded then weekly return visits would be required. By removing the old cotton and clearing the sulcus of skin debris and or callus then applying new cotton wool, the cushioing effect would take place for the next week or two. The patients appreciate the extra attention and the return visits would last less than 10 minutes.
  17. LuckyLisfranc

    LuckyLisfranc Well-Known Member


    The posts on this thread has caused me to groan with embarrassment more than most lately.

    WTF are we doing talking about sticking bits of cotton wool down the sides of people's toenails! Are we still in the Victorian era? Do you sharpen you scalpel blades with a strop too?

    Please. Spare me. Imagine going to court to defend this if it ever became osteomyelitis.

    Show some professionalism. Just stick some local anaesthetic in the toe and fix the bloody thing.

  18. Catfoot

    Catfoot Well-Known Member

    Robin P,
    You think you're funny, but you're not. I didn't get a response, that's why I asked the question again after a week.

    Lucky Lisfranc,
    You read my mind and also posted just before I did.

    Are the patients now telling you how to treat them? B£oody stroll on. :bang:

    I just hope members of the public don't read this cr@p.

  19. blumley

    blumley Active Member

    as a student im curious and slightly concerned at the varying treatments that seemed to be offered for this case.

    although im very inexperienced i always thought pna was the best treatment in this case? although i have seen a lecturer placing cotton wool under the nail this didnt seem to be a long term option and the patient was advised that surgery would be needed if the problem continued.

    what would you all recomend if the pt is unwilling to have the pna? sorry if any of those points seem a bit dumb im just a curious student.
  20. Catfoot

    Catfoot Well-Known Member

    Hello blumley,
    You are quite correct

    again correct.

    I have tried packing nails but only as a very short-term measure. These type of cases usually end up as a pna.

    If the patient refuses to have a pna, then that is their choice, but it must be explained to them very clearly that the problem will not resolve without this intervention. If this was the case I would would treat conservatively but continue to encourage them to go ahead with nail surgery. The large majority of patients eventually come around to the idea of a pna, as these type of cases can be quite painful.


  21. Steve_Pod

    Steve_Pod Member

    Sorry patients don't tell me how to treat their conditions. I interact with patients and their feedback and adjust my treatments that works in the patient's favour. When I used the cotton wool packing and Friar's Balsam, I advised them that they may be pain free for up to 2 months but sometimes the pain of an ingrowing nail could recur within a few weeks. For the patients who complained of pain in the sulcus a week or two later, then the cotton packing and repacking protocol was done either weekly or biweekly until the nail grew out of the sulcus and was beyond the skin. This was done for patients who did not want a PNA (or could not have one) and for an affected sulcus where the skin is intact and not septic!

    BTW, I had one NIDDM patient with a chronic ingrown toenail and I carefully kept dressing and redressing it monthly and advised patient to do home treatments with saline foot soaks and antibiotic cream application. In spite of my conservative treatment protocol, she ended up with a below knee amputation. Thankfully I used the antiquated and almost forgotten Victorian and Edwardian and Pasteurian and even Semmelweis technique as applied to chiropody and although the patient did end up with one good leg to stand on, I was not responsible either directly or indirectly to the BKA. If another colleague chose to simply treat the ingrown toenail with a modern PNA (and even decided to show off the effectiveness of a LASER) the patient may have had to undergo a BKA within a week or two. Whereas I was working diligently to try to prevent further infection and conservative treatment did not work after a 3-4 month period.
  22. Kara47

    Kara47 Active Member

    Catfoot, Cornmerchant & co,
    It would be useful to hear what other options a patient can be offered if they don't want or can't have a PNA. Would you do a PNA on a patient with a high risk foot, poorly managed diabetes or vascular insufficiency? It's good to see a range of treatments offered, maybe you could contribute something useful instead of nasty comments?
  23. RobinP

    RobinP Well-Known Member

    Yes, one would hope not. Especially with this level of dialogue
  24. Catfoot

    Catfoot Well-Known Member

    There are a few conservative option available to those who don't want nail surgery :- nail packing, nail bracing, and using mild keratolyics in the sulcus, (if that where the problem is).
    All come with their own set of problems, none are very effective and all consign the patient to 3/4 weekly trips to the surgery for ever and a day. This, to me, would give a poor quality of life, not to mention the expense if they were visiting a private practitioner.

    IMO a TNA would sort the problem once and for all, free the patient from regular surgery visits and give a more positive outcome.

    "No" to all three scenarios as I am in Private Practice in UK. These patients should be under the care of the NHS specialist Podiatry Teams where there is backup available, including an out-of-hours emergency service.

    When I did work with Diabetics in the NHS many years ago the outcome for these patients was often poor and often resulted in various stages of amputation.

    Let's draw a parallell with dentisty - ask yourself this question :- "How much ongoing root canal work would you be prepared to tolerate on a back molar in a vain effort to save a tooth that was severely compromised?" My response would be "not much" and I'd soon be agreeing to an extraction.

    Sometimes, despite our best efforts, we just can't fix it.


  25. lusnanlaogh

    lusnanlaogh Active Member

    By that, I hope you don't mean "Let's have the amputation and be done with it."?

    Whilst it's true that sometimes, despite our best efforts, we just can't fix it, often there is much to be said for conservative treatment styles such as that offered by Steve_Pod. A little empathy wouldn't go amiss, either.

    Btw, I love this forum (!), but sometimes the 'pack mentality' can get a bit much ... !
  26. Catfoot

    Catfoot Well-Known Member


    Not in so many words, but sometimes a digital amputation today is better than a mid-thigh amputation next week. I am talking here about high risk patients.

    To return to the original posting - we don't have the advantage of either seeing a picture of the toe. Neither has anyone, including the OP seen what the toe was like prior to this rather radical nail-cutting that has been described.

    Some patients, unfortunately, have deep sulci, fan-shaped nails etc etc and other structural anomalies that cause problems despite the best efforts of any chiropodist.

    IMO conservative treatment is a short-term option, and far too many practitioners continue without offering an alternative, more permanent, solution.


  27. lusnanlaogh

    lusnanlaogh Active Member

    Yes, I understand, but this forum is public (as someone mentioned earlier up the thread) and (you probably don't realise?) for some people a digital amputation can have as much impact as someone else having an AK.

    I agree - a photo would be very helpful!

    I partially agree with you here: sometimes, patient choice and health issues don't allow a TNA or a PNA. In which case, I am pretty certain most patients would wish for conservative treatment. ;)

    Personally, I prefer patients to come back as infrequently as possible ... given a healthy patient who wanted to get rid of the problem I would probably opt for TNA or PNA.

    However, if the odds were stacked against that option ... one treatment I have used (usually, very successfully) in the past is, instead of cotton wool (which, I've found rucks up into tiny balls), is either Bactigras tulle or Inadine. The tulle does its stuff and (generally) stays in place, so the time between appts is usually more acceptable to pts.
  28. Catfoot

    Catfoot Well-Known Member


    A good point.

    However, if the patient's foot health status is so compromised that surgical intervention is contraindicated, I would question the wisdom of packing the nail(sulci) with anything?

    As we know, the sulci is continuous with the nail matrix and nail walls and it is of paramount importance not to break this "seal" and allow the incursion of pathogens. I have see far too many cases of paronychia and "the greenies" to recommend nail-packing as a matter of course.
    And there will always be patients who will persist in fiddling with whatever dressing you put on.

    In my experience, repeated packing sometimes only results in a tight sulci being changed into a relaxed sulci, which has its own set of problems.

    So it seems we are between a rock and a hard place here.

    So I'm still not convinced as to the efficacy of nail-packing in the longterm.


  29. lusnanlaogh

    lusnanlaogh Active Member

    Good point. However, akthough I rarely do it, I still think there's a place for (gentle) nail packing.

    I feel we're going around in circles here. A photo would be such a good idea ... we'd then be able to offer informed advice.
  30. Steve_Pod

    Steve_Pod Member

    Packing a sulcus where the skin is intact, works and the cotton provides a cushion for a few weeks. The simple procedure provides relief that the patient's MD or NP cannot provide.

    The other contra-indication would be an allergy to Friar's Balsam. During the past 30 years of doing this technique, I have been able to provide much relief for patients and have not seen an allergic reaction to Friar's Balsam.

    I also do PNAs and TNAs when required and if the cotton packing doesn't help.

    Patients are always advised that packing may help but if it doesn't, then a PNA or TNA should be considered. If the patient is at high risk, I don't attempt the PNA or TNA and refer the patient to an orthopaedic surgeon.

    Pictures before and after actually would show nothing as the wisp of cotton is small and in the after picture you would see a slight brown stain in the sulcus and on the nail. So I'm not submtting or attaching or providing a site where pictures can be viewed.
  31. Catfoot

    Catfoot Well-Known Member


    I absolutely agree, as this discussion is really just academic.

    I hope the OP can post one.


  32. lucyjones79

    lucyjones79 Welcome New Poster

    I am not seeing the patient for several weeks, so I will try and provide a picture towards the end of this month, as I believe this is when I will be seeing her again.

    Thanks for everyone's input, and I can see this is a slightly divided issue so am greatful for several differing opinions on the topic.
  33. LuckyLisfranc

    LuckyLisfranc Well-Known Member


    I think there are two different issues in this thread, which is introducing confusion.

    Your original post related to a painful nail deformity in the assumed absence of ischaemia. Whilst palliation is not inappropriate, it is not curative. A bit like seeing a dentist every month for the rest of your life to fiddle with a painful tooth, that could be easily extracted following the inconvenience of a little local anaesthesia.

    Others here have replaced your patient with a separate straw man argument. Yes, the only firm total contraindication to a curative nail procedure that I am aware of is moderate to severe ischaemia, either due to microvascular issues (eg scleroderma/Raynauds) or macrovascular (PAD). All other comorbidities introduce relative risk, which is often managable.

    As you have not indicated any significant ischaemia is present, then just be the 'doctor' and be polite and firm with your patient about what is the most appropriate way to deal with it.

  34. footdrcb

    footdrcb Active Member

    The answer is very simple. TNA.
  35. Heather J Bassett

    Heather J Bassett Well-Known Member

    Hi Lucy, you certainly started an interesting thread. 3 decades ago we were all taught to pack the sulci with involuted nails. Nails were all to be cut straight across. Debriding and enucleating onychophosis was minimal.
    I have no doubt that many still continue to use this form of treatment and there are clients who are happy with this.
    Personally I have not packed a sulcus for many years. Redefining the nails through cutting and blacks filing on a regular maintenance basis is a very effective treatment for those who chose to avoid surgery. One draw back with this is ageing. Involuted nails tend to become worse over time, add the increasing fragility of the sulci, the onychauxic nature of ageing nails and by the time some clients admit that surgery is there best option there risk status is too high.
    Educating clients on the long term prognosis is an important part of treatment and helps the client to make an educated decision.
    Addressing the external factors of poor biomechanics that are often involved and inappropriate footwear is also important in the overall managment of this condition.
    Discussing the type of problems that I have seen watching clients age over almost 30 years is an added bonus when recommending early surgical intervention can be a bonus.

  36. Avoca Footcare

    Avoca Footcare Welcome New Poster

    This is my first and last post to this site, as I have no intention of returning to read this level of abuse towards fellow colleagues. Ask yourselves would you see this low level of abusive, non-constructive, mocking communication between neuro-surgeons? No you would not - because they are professional and respect fellow professionals - take my point!
  37. Catfoot

    Catfoot Well-Known Member

    Avoca footcare,
    For a first post you aren't being very constructive, just stopping any further exchange of ideas.

    I am not sure what "abuse" you refer to? On this site there is often a robust exchange of views.

    If you tell what has got under your skin, maybe it would spark more discussion.



    PS Do neurosurgeons have a forum ??

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