What are the steps for performing a total or partial toenail removal (avulsion) using a sterile outpatient technique with local anesthesia?

Toenail Removal Procedure Steps

Toenail avulsion is performed under digital nerve block anesthesia using lidocaine with epinephrine (maximum 7 mg/kg), followed by tourniquet application, nail plate elevation and removal with a nail elevator and hemostat, and post-procedure wound care with antibiotic ointment and pressure dressing. 1, 2

Pre-Procedure Preparation

• Obtain informed consent explaining the procedure, risks, and expected outcomes 3
• Position the patient supine with the foot accessible
• Prepare sterile field with antiseptic solution
• Gather instruments: nail elevator, hemostat, scissors, tourniquet (Penrose drain or rubber band), gauze, antibiotic ointment

Anesthesia Administration

Perform a complete digital nerve block rather than local infiltration for optimal pain control 3, 4:

• Use lidocaine with epinephrine (1:200,000 dilution) at maximum dose of 7 mg/kg 1
• Inject at the base of the toe on both medial and lateral sides to block the digital nerves
• Aspirate before each injection to avoid intravascular administration 1
• Use incremental injections rather than bolus dosing 1
• Wait 5-10 minutes for complete anesthesia to take effect
• For lidocaine allergy (rare, only 1% of reactions): use ester-type anesthetics, 1% diphenhydramine, or bacteriostatic saline 1

Nail Avulsion Technique

Apply a tourniquet at the base of the toe to create a bloodless field 5, 6:

• Use a Penrose drain or rubber band wrapped around the toe base
• This improves visualization and reduces bleeding

For partial nail avulsion (e.g., ingrown toenail):

• Insert nail elevator under the affected portion of the nail plate
• Separate the nail from the nail bed with gentle sweeping motions
• Use hemostat to grasp the separated portion
• Pull the nail segment straight out in the direction of growth
• Remove any remaining nail fragments

For total nail avulsion 7, 5:

• Insert nail elevator under the proximal nail fold
• Advance the elevator distally to separate the entire nail plate from the nail bed
• Work laterally to free both sides of the nail
• Use hemostat to grasp the freed nail plate at its proximal end
• Remove the entire nail in one piece by pulling straight out 7
• Inspect the nail bed for remaining fragments and remove them

Post-Avulsion Management

For ingrown toenails requiring permanent correction, perform chemical matricectomy immediately after avulsion 3:

• Apply silver nitrate sticks to the exposed nail matrix for 1-2 minutes
• This prevents recurrence by destroying nail-producing cells
• Neutralize with saline or alcohol after application

Wound care 2, 5:

• Release the tourniquet
• Apply antibiotic ointment to the nail bed
• Place non-adherent gauze over the wound
• Apply pressure dressing to control bleeding
• Elevate the foot for the first 24 hours

Post-Procedure Instructions

• Keep the dressing dry for 24-48 hours
• Expect drainage and mild bleeding initially 7
• Change dressings daily with antibiotic ointment application
• Taping may be beneficial for conditions like pincer nail to guide proper nail regrowth 7
• Pain typically resolves quickly; analgesics needed for only 1-3 days 8
• Return to normal footwear in 1-2 weeks
• New nail regrowth takes 3-6 months 7

Common Pitfalls to Avoid

• Inadequate anesthesia: Always perform complete digital nerve block rather than local infiltration for better pain control 3, 4
• Incomplete nail removal: Leaving nail fragments causes persistent pain and infection risk 2
• Skipping matricectomy for ingrown toenails: This leads to high recurrence rates 3
• Excessive tourniquet time: Remove within 15-20 minutes to avoid ischemic complications
• Not aspirating before injection: Risk of local anesthetic systemic toxicity 1