Nail Removal: Procedure Demonstration

00:01 Okay, now it's time to do the procedure.

00:04 So the first thing that we're going to need to do, I've already soaked the toe in the basin like I talked about with iodine.

00:11 Um, and now I'm preparing to be able to do the digital block.

00:16 We've already gotten consent from the patient as well.

00:19 So I'm going to need the clear clean the area with chlorohexidine.

00:26 So I'm going to clean really good here on the side of the toe in the midline area of the toe as well, because this is where we're going to be doing the injection.

00:36 So this is what I'm going to do right now. And then we'll come back and clean again as well. So I have lidocaine without epi 1%.

00:45 We're going to do a digital block.

00:48 And we're going to do this in the webbing of the the toes here.

00:52 So you're going to want to let the patient know that there's going to be some burning sensation. And this is going to be a little painful, but it will help later.

00:59 So you want to go in here to the toe webbing, and you're going to make sure when you get in place that you do not have any blood withdrawal. If you don't, then you're going to push forward some lidocaine. You want to make sure that you go come out just a little bit, and you're going to go down a little bit more dorsal and inject a little bit more.

01:26 And then you're done with that side.

01:27 And you're going to come and you're going to do this on the outside area as well.

01:33 You can inject again. You're going to withdraw back to make sure you don't have any blood draw, and you're going to inject forward, and then you're going to want to pull out just a little bit.

01:43 And you're going to go down more dorsal and inject as well.

01:48 Then you're going to remove.

01:50 I would put this back on your sterile field as the patient may need additional anesthetic. But you want to give this 5 to 10 minutes.

01:58 This is a great time for you to run and go see another patient and come back.

02:03 Now that we've finished that, we want to make sure that we clean the whole entire toe with chlorhexidine wipe.

02:12 So we're going to clean the toe very well.

02:15 This is the side that we're going to be removing today.

02:21 Okay. Now I'm going to throw that in the dirty.

02:25 Now we're going to see if the patient has any pain.

02:29 I like to use the forceps that have the little grabber points on it.

02:33 And I would actually be touching the patient to see if there's any pain.

02:37 They should feel pressure, but they should feel no pricking sensation.

02:42 This patient is numb. So we're going to continue forward with our demonstration.

02:47 So now I like to take these straight blade scissors.

02:51 And you're going to cut at an angle.

02:53 And you're going to go up underneath the nail.

02:55 So you kind of have to hold the tip of the nail and the back of the toe.

02:59 And you're going to cut down the middle.

03:04 And this takes a little bit of work because toenails are not the softest thing in the world. So it takes a little bit because you're actually pulling it away from the nail bed. You're going to just continue to cut until you get to all the way to the back of the toe. Sometimes this may ask you to actually put the toe in your hand in a little bit better situation to be able to get better grab.

03:32 You can also, at this point, if you needed to, set down your scissors and take your elevator to try to elevate the nail a little bit.

03:44 Remember, the patient is not feeling pain, they are just feeling pressure.

03:52 I'm talking to you in this video, but what I like to do is talk to my patients while I'm doing this procedure and ask them about their vacations or what they've been doing for the day. This is very helpful to keep the patient calm as you're going through your procedure. Now you can see I've split all the way to the back of the nail.

04:14 Now it's time to take your hemostats.

04:18 We're going to move in a back-and-forth motion rather than a lateral motion, and you're going to completely remove the nail.

04:28 And then as you can see, the lower part, if we had a true ingrown toenail, would have a little bit more extension on it.

04:37 Now that we have this this would be bleeding.

04:40 So we would want to get homeostasis.

04:43 So you would apply pressure.

04:45 The other thing that I talked about is you could use cautery pins or you could also use Monsel's solution. The way that would work is you would dip your Q-Tip in the Monsell solution, and you would lightly press it on the skin.

04:58 It would cause a darkening look around it.

05:03 The other thing that we're wanting to do, when we can see clearly because there's no more bleeding involved, is we want to make sure that the nail matrix looks okay, that the nail beds good, that there isn't any free debris.

05:16 Sometimes with an ingrown, you may have a little more skin growth here that actually you might want to use your surgical scissors to actually remove.

05:28 With a regular nail. This is of course a model.

05:32 This would be a better line and you would not have the rough edges here.

05:38 Once you have achieved hemostasis now you want it to clean the nail bed.

05:42 And we would do that with sterile water.

05:45 And so we want to make sure that we're removing any of the old or dried blood around here so that we have a good healing process take place.

05:52 Next, if you wanted to apply antibiotic cream, you could do that with a Q-Tip, applying it to the whole nail bed.

05:59 And then you want a non-adherent dressing over this.

06:02 And so I took a larger dressing that I had here and cut it down to size.

06:07 Typically, you could use a tail flare dressing here as well, which may not have the adhesive borders, but you could use it and then use additional tape to help secure that.

06:17 So I'm going to apply this.

06:21 And this can be done by you.

06:23 Or it could be done by your medical assistant.

06:25 Whoever is available to be able to do this.

06:27 But make sure that the wound bed actually has the Telfa there, the non adhesive dressing.

06:37 Okay. And this looks like I need to cut it down a little bit more.

06:40 So you're going to be able to do that with your scissors.

06:47 So I'm going to cut up above here making sure that you're not cutting the toe.

06:53 So be very careful of what you're doing.

06:57 I'm actually going to straighten out the dressing and take it off for just a second to finish doing this. Dressing a wound is not perfect, so sometimes it takes several times to get it correct.

07:12 That's okay. So now we're going to put this over the wound bed again, securing it. And then I also like to take a 4x4 here.

07:26 And you're going to fold it in half.

07:29 And I lay it this way over the wound.

07:33 And then you're going to take your clean wrap.

07:39 I prefer to use clean wrap versus coban because you have more control over it not getting too tight and cutting off blood flow.

07:53 So I go several times around this way.

08:01 As well as turning slightly and going up and down the toe this way to secure it as well.

08:08 And then going back around and back around and then secure, coming over one more time, then you're going to cut this.

08:18 There is no perfect way to do this.

08:21 You're just wanting to secure this so it will stay.

08:24 And hopefully, they will still not have any bleeding again.

08:29 You can instruct them to reinforce this area if they need to, but if they've reinforced it already once, then they need to call your office.

08:39 Or if they have extensive bleeding, they need to call the office because something else will have to be done.

08:47 You just want to make sure that the base is secure.

08:50 And again you're going to have them check.

08:54 You may tell them to check to make sure there's no blanching here at the base of the toe, and that in 6 to 8 hours, when they start to feel the sensation again, that they can feel the sensation appropriately.

09:05 But you're going to test that as well at the end of your procedure.