What are the management options for a patient experiencing severe pain on day 5 after toenail surgery?

Severe Pain on Day 5 After Toenail Surgery

Excruciating pain on postoperative day 5 after toenail surgery is abnormal and demands immediate evaluation for complications—specifically infection, abscess formation, or inadequate surgical technique—before simply escalating pain medications. 1

Immediate Assessment for Complications

You must urgently evaluate for the following complications, as worsening pain at this stage signals a problem rather than normal postoperative recovery:

• Infection or abscess formation: Look for increased erythema beyond the immediate surgical site, purulent or foul-smelling drainage, warmth extending proximally, lymphangitic streaking up the foot, or fever >38°C (100.4°F). 1 Surgical site infections after toenail surgery can progress to severe complications including gangrene requiring amputation if not recognized early. 2

• Wound dehiscence or hematoma: Directly inspect the surgical site for separation of wound edges or collection of blood under the skin. 1

• Compartment syndrome (rare but critical): Assess for tense swelling of the toe with neurovascular compromise, including diminished capillary refill, pallor, or numbness. 1

• Osteomyelitis: Consider this in patients with long-standing ingrown toenails or persistent infection, as bone involvement requires specific antibiotic treatment beyond routine wound care. 3

Pain Management Algorithm (After Excluding Complications)

Once you have ruled out complications requiring surgical intervention or antibiotics, implement this stepwise approach:

First-Line: Multimodal Non-Opioid Regimen

• Acetaminophen 1 gram every 6-8 hours scheduled (not as needed), which forms the cornerstone of postoperative analgesia with superior safety. 4, 5, 1

• NSAIDs scheduled: Ibuprofen 400-600mg every 6-8 hours OR naproxen 500mg twice daily, unless contraindicated by renal disease, active peptic ulcer, or bleeding disorders. 4, 5, 1 NSAIDs are highly effective at reducing pain intensity and should not be withheld based solely on theoretical bleeding concerns. 5

Second-Line: Short-Acting Opioids for Breakthrough Pain Only

If pain remains uncontrolled despite scheduled acetaminophen and NSAIDs:

• Tramadol 50-100mg every 6 hours OR oxycodone 5mg every 4-6 hours for breakthrough pain only. 1

• Never use long-acting or extended-release opioid preparations (such as extended-release oxycodone, morphine, or fentanyl patches), as these increase respiratory complications and harm without improving pain control in the postoperative period. 4, 5, 1

When to Escalate Care Immediately

Refer the patient back to the surgeon or emergency department if any of the following develop:

• Fever >38°C (100.4°F). 1
• Purulent drainage or spreading cellulitis. 1
• Pain that continues to worsen despite appropriate multimodal analgesia. 1
• Any signs of neurovascular compromise (numbness, pallor, absent pulses). 1

Monitoring and Follow-Up

• Reassess within 24 hours after initiating treatment changes to evaluate pain control and wound status. 1

• Document pain scores using a numeric rating scale (0-10) both at rest and with ambulation, as this validated tool correlates strongly with patient experience and guides treatment adjustments. 4, 1

• If prescribing opioids, provide specific instructions on safe administration, a defined weaning schedule (typically 3 days or less for acute pain), and proper disposal of unused medications. 4, 1

Critical Pitfalls to Avoid

• Do not simply increase opioid doses without first evaluating for complications, as pain escalation at day 5 is a red flag for infection or other surgical problems, not inadequate analgesia. 4, 1

• Do not use "as needed" dosing for acetaminophen and NSAIDs in the first week postoperatively; scheduled administration provides superior pain control and reduces total opioid consumption. 5

• Do not prescribe opioids "just in case" pain continues, as each unnecessary day of opioid exposure increases risk of physical dependence without adding benefit. 4

• Do not delay wound inspection based on the assumption that pain is normal; direct visualization of the surgical site is mandatory when pain worsens or persists beyond expected recovery. 1