Last reviewed: March 2026
Contents
MDM Templates
Ingrown Toenail
Patient presents with pain and swelling around the nail fold consistent with ingrown toenail. This is a recurrent problem for the patient. No signs of cellulitis extending beyond the periungueal tissue. No concern for osteomyelitis or deeper infection.
Partial nail removal performed with significant patient relief.
Plan: Wound care. Warm soaks daily.
Disposition: Discharge with return precautions for worsening redness, spreading infection, or fever. Follow up with PCP within 1 week.
Subungual Hematoma
Patient presents with subungual hematoma after injury within the last 48 hours. No overt evidence of flexor or extensor tendon dysfunction, compartment syndrome, or neurovascular injury. Imaging without fracture.
Nail trephination performed with excellent drainage and pain relief.
Plan: Warm water soaks 2–3 times daily for 1 week. Splinting deferred given no fracture.
Disposition: Discharge with return precautions and PCP follow-up within 1 week.
Nailbed Laceration
Patient presents with nail injury and nailbed laceration after trauma. Neurovascular exam intact distally. Flexor and extensor tendon function intact.
Nailbed repaired primarily. Patient counseled that nailbed disruption can lead to permanent cosmetic nail changes despite optimal repair.
Plan: Wound care. Prophylactic antibiotics.
Disposition: Discharge with 48-hour wound check and PCP follow-up.
Procedure Notes
Partial Nail Removal
Location: *** nail
Time Out: Correct patient, correct procedure confirmed
Anesthesia: Digital block with *** lidocaine
Method: A needle driver was used to elevate the nail. The nail was detached from the cuticle in standard fashion. The affected portion (approximately one-third) of the nail was removed on the involved side. No disruption of the nailbed matrix
Complications: None. Patient tolerated procedure well with significant relief.
Nail Trephination
Location: *** nail
Time Out: Correct patient, correct procedure confirmed
Approach: Nail prepped and cleansed in sterile fashion
Method — Cautery technique: Handheld cautery heated and applied to the nail with gentle pressure to create a tract through the nail without penetrating the nailbed. Significant drainage of blood with resolution of the subungual hematoma. Nail trephinated a total of *** times to provide excellent relief
Method — 18-gauge technique: An 18-gauge needle applied to the nail with gentle pressure and rotated rapidly to drill through the nail without penetrating the nailbed
Complications: None. Patient tolerated procedure well.
Nailbed Laceration Repair
Location: *** digit, *** hand
Time Out: Correct patient, correct procedure confirmed
Anesthesia: Digital block with *** lidocaine
Approach: Nail removed to expose nailbed laceration. Wound copiously irrigated with normal saline under high-pressure volume. No foreign bodies noted
Repair: Nailbed laceration closed using 5-0 Vicryl Rapide in interrupted fashion. Excellent care taken to achieve best possible cosmetic alignment of the nailbed
Associated skin repair: *** (if applicable, 4-0 Vicryl interrupted)
Dressing: Dry sterile dressing applied
Complications: None. Patient tolerated procedure well. Patient counseled regarding potential for adverse cosmetic nail effects from nailbed disruption.
Clinical Education
Ingrown Toenail Pearls
Partial nail removal is curative for most presentations. Remove the offending lateral edge — you don’t need to remove the entire nail. For recurrent ingrown nails, chemical matrixectomy with phenol (88% phenol applied to the nail matrix after partial avulsion) reduces recurrence from ~70% to ~5%. This can be done in the ED but is more commonly an outpatient procedure.[1]
Antibiotics are rarely needed. Most ingrown toenails are inflamed, not infected. If there is significant surrounding cellulitis or purulent drainage, treat as a skin and soft tissue infection with appropriate coverage. For diabetic or immunocompromised patients, lower your threshold for antibiotics and close follow-up.
Subungual Hematoma Pearls
Trephination relieves pain regardless of hematoma size. The old teaching of “only trephinate if >50% of the nail” has been challenged — trephinate any painful subungual hematoma. The key question is whether there’s an underlying nailbed laceration. If X-ray shows a distal phalanx fracture, the risk of nailbed laceration is higher, but trephination alone (without nail removal and nailbed exploration) produces equivalent cosmetic and functional outcomes in most cases.[2]
Do not trephinate acrylic nails with cautery — fire risk. Use the 18-gauge needle technique instead.
Nailbed Laceration Pearls
The nailbed is the template for the new nail. Accurate repair of the sterile matrix (the portion adherent to the nail) is critical for a cosmetically acceptable nail. Use 5-0 or 6-0 absorbable suture (Vicryl Rapide is ideal — dissolves on its own, no removal needed under the nail). After repair, replace the nail plate (or use a silicone sheet) as a splint to keep the nail fold open for the new nail to grow through.[3]
Germinal matrix injuries (the proximal white crescent) carry the worst cosmetic prognosis. These patients need meticulous repair and should be warned about potential permanent nail deformity.
References
- Heidelbaugh JJ, Lee H. Management of the ingrown toenail. Am Fam Physician. 2009;79(4):303-308. PubMed
- Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg Am. 1999;24(6):1166-1170. PubMed
- Zook EG et al. Anatomy and physiology of the perionychium: a review of the literature and anatomic study. J Hand Surg Am. 1980;5(6):528-536. PubMed
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