Case Study

Onychogryphosis treated with palliative care

A 73-year-old man with type 2 diabetes of 1 year's duration complained of deformity of his left first toe nail of many years' duration (he had dropped an ammunition box on it). He did not like the appearance of the nail and said that it wore holes in his socks. He was asked to attend the diabetic foot clinic at 3-monthly intervals and the thickened nail was reduced with scalpel and file. He had no further complaints.

Key points

• Cutting and thinning gryphotic nails can avoid surgery in patients who are prepared to attend regularly

• Reduction of thickened nails improves the cosmetic appearance to near-normality.

Onychocryptosis (ingrowing toe nail) This is frequently caused by improper nail-cutting technique, when a spike of nail is left behind at the side of the nail. As the nail plate grows forward the spike is pushed into the nail sulcus (the groove of flesh at the side of the nail). Other causes of onychocryptosis include pressure on the side of the nail from tight shoes or tight socks, antithrombotic stockings or support hose, or a trauma to the side of the nail, as when the toe is stubbed. Some teenagers with a very thin nail plate and a fleshy nail sulcus are particularly prone to onychocryptosis.

Treatment of onychocryptosis involves removal of the offending splinter (nail spicule) (Fig. 2.5a,b), and the ragged edge of the nail is then filed smooth with a Black's file (a small file specially designed to fit into the sulcus and under the nail). Unless the splinter is removed quickly, the spike of nail will penetrate the flesh, and in these circumstances infection rapidly supervenes. Where onychocryptosis is recurring or chronic it can be treated very successfully with partial nail avulsion under local anaesthetic (without adrenaline). Phenolization of the exposed area of nail bed to prevent regrowth of the troublesome side of the nail prevents recurrence. This procedure should not be performed on ischaemic feet.

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