Is an intramuscular (IM) injection suitable for pain management in nail avulsion?

Intramuscular Injection is NOT Recommended for Pain Management in Nail Avulsion

Intramuscular (IM) injection should be avoided for pain management during nail avulsion procedures; instead, use local anesthesia with or without epinephrine (1:200,000 dilution) injected directly at the surgical site. 1

Why IM Injection is Inappropriate

IM Route is Contraindicated for Procedural Pain

• Intramuscular administration of analgesics is explicitly not recommended because of injection-associated pain itself 2
• The IM route does not allow for medication titration and causes pain both at the time of delivery and for days afterward 2
• IM injections should be eliminated whenever possible as they are inherently more painful than alternative routes 2

Proper Anesthesia for Nail Avulsion

Local anesthesia is the standard of care for nail avulsion procedures:

• Nail avulsion is most commonly performed under local anesthesia with or without epinephrine (1:200,000 dilution) injected directly into the digit 1
• This provides targeted pain control at the surgical site without the systemic side effects or injection pain associated with IM routes
• The procedure can be safely performed in outpatient settings with local anesthesia alone 3

Recommended Pain Management Algorithm

For the Procedure Itself:

1. Primary approach: Inject local anesthetic (lidocaine with or without epinephrine 1:200,000) directly into the digit using proper digital block technique 1
2. Minimize injection pain: Use buffered lidocaine with bicarbonate, warm the anesthetic, inject slowly with a small-gauge needle 2
3. Consider topical anesthetics: Apply topical anesthetic (LET or EMLA) to intact skin before local injection if time permits 2

For Post-Procedure Pain:

• Oral analgesics (NSAIDs or oral opioids) are appropriate for post-procedure pain management 2
• Provide around-the-clock dosing instructions for anticipated moderate pain 2
• Intravenous route is preferred over IM if parenteral opioids are needed for severe pain, as it allows for titration and rapid relief 2

Critical Pitfalls to Avoid

• Never use IM injection as the primary pain management strategy for nail avulsion—it adds unnecessary pain without procedural benefit 2
• Avoid confusing the route of anesthesia delivery: local infiltration at the surgical site is fundamentally different from systemic IM injection 1
• When IM route is absolutely necessary for other indications, use the shortest needle length possible and apply concurrent manual pressure to reduce pain 2