What are the next steps for a patient experiencing excruciating pain on post-operative day 5 following ingrown toenail surgery?

Excruciating Pain on Post-Operative Day 5 After Ingrown Toenail Surgery

This level of pain on post-operative day 5 is abnormal and requires immediate reassessment for surgical complications, particularly infection, abscess formation, or inadequate surgical technique, before escalating analgesic therapy. 1

Immediate Assessment Required

A sudden increase in pain intensity, especially this far post-operatively, mandates urgent comprehensive evaluation for postoperative complications rather than simply increasing pain medications. 1 Specifically evaluate for:

• Infection or abscess formation - Look for increased erythema, purulent drainage, warmth, lymphangitic streaking, or fever 1
• Inadequate surgical excision - Persistent granulation tissue or retained nail spicule causing ongoing trauma 2
• Compartment syndrome of the toe - Though rare, assess for tense swelling and neurovascular compromise 1
• Wound dehiscence or hematoma - Examine the surgical site directly 1

Pain at this stage should be decreasing, not excruciating. 1 Do not simply administer additional opioids based on elevated pain scores alone without this comprehensive assessment. 1

Pain Management Algorithm While Evaluating

First-Line Multimodal Approach

• Acetaminophen 1 gram every 6-8 hours scheduled (not as-needed) forms the cornerstone of postoperative analgesia 3
• NSAIDs (ibuprofen 400-600mg every 6-8 hours or naproxen 500mg twice daily) unless contraindicated by bleeding risk or renal dysfunction 1, 3
• Elevate the foot above heart level to reduce inflammatory edema 4
• Ice application for 15-20 minutes every 2-3 hours to reduce inflammation 4

Second-Line for Breakthrough Pain

If the multimodal non-opioid regimen fails to control pain after complications are excluded:

• Short-acting oral opioids only - tramadol 50-100mg every 6 hours or oxycodone 5mg every 4-6 hours for severe breakthrough pain 3
• Avoid long-acting or modified-release opioid preparations entirely as they are associated with increased harm in the postoperative period 1, 3

Adjunctive Measures

• Topical mid- to high-potency corticosteroid applied to inflamed periungual tissue if infection is excluded 4
• Warm soaks in Epsom salt solution 2-3 times daily if wound is healing appropriately 5, 4

When to Escalate Care

Refer back to the surgeon or to emergency care immediately if: 1

• Fever >38°C (100.4°F) develops 1
• Purulent drainage or spreading cellulitis is present 5, 4
• Pain continues to worsen despite appropriate analgesia 1
• Neurovascular compromise develops 1

Surgical Re-Intervention Considerations

If infection or inadequate initial surgery is identified, the patient may require:

• Incision and drainage of abscess if present 5
• Revision surgery to remove retained nail spicule or inadequately excised granulation tissue 2, 6
• Chemical matricectomy with phenol if recurrent ingrowth is occurring 5, 4

Critical Pitfalls to Avoid

• Never escalate opioids without excluding surgical complications first - increased pain intensity at post-operative day 5 is a red flag for complications, not an indication for more narcotics 1
• Do not rely on "as-needed" dosing of non-opioid analgesics - scheduled acetaminophen and NSAIDs provide superior pain control 3
• Do not dismiss patient reports of severe pain - provide empathy and active listening while conducting thorough evaluation 1
• Avoid prescribing modified-release opioids or transdermal patches without specialist consultation, as these are associated with respiratory complications 1, 3

Monitoring and Follow-Up

• Reassess pain and wound status within 24 hours after initiating treatment changes 1
• Document pain scores using validated scales both at rest and with ambulation 1
• If opioids are prescribed, provide specific instructions on safe administration, weaning schedule, and proper disposal of unused medications 1
• Ensure timely communication with the operating surgeon regarding persistent severe pain 1