While many of the cases we see here at the Auckland Ingrown Toenail Clinic are fairly standard, there are a few that vary greatly from the ‘norm’, and could have resulted devastating consequences if they had been left untreated under the hopes that the ingrown nail would “go away on its own”, something many people do. This is a case in which Billy’s ingrown toenail was harbouring a bone infection that he didn’t know about, including his signs, symptoms and treatment.

Initial Consultation

When we first met Billy, he came in limping slightly, and seemed frustrated and uncomfortable with his ingrown nail, given that he’d been hoping that if he left it for long enough, it would resolve on its own. Billy is a middle-aged man, generally in good health. He said something along the lines of: “It’s just an ingrown toenail, but it feels like it’s taking over my life”.

Billy described his toe pain as persistent and worsening, especially when wearing shoes. The affected toe was visibly swollen and red, signs typical of an ingrown toenail, but there was a severity to his discomfort that raised concerns that we need to look further and rule out the possibilities of anything more serious – an important part of all of our ingrown toenail consultations.

Examination and First Impressions

Upon examining Billy’s toe, his podiatrist noticed the unusual degree of tenderness in the surrounding area, extending beyond the immediate vicinity of the toenail itself. The skin was quite warm to the touch. The toe was extremely sensitive, and there was notable redness around the area. 

Given the intensity of the pain (and a gut feeling that this went beyond ‘typical’), we recommended an x-ray to rule out any deeper complications, such as a bone infection. We explained how, in uncommon cases, an untreated ingrown toenail could lead to more serious infections, potentially affecting the bone. Billy was surprised, but agreed to having the scan to rule out the possibility. 

Diagnosis

The x-ray showed a slight erosion visible on the bone beneath the toenail, indicative of osteomyelitis—a bone infection. This is very important information that shifts a proposed management plan dramatically. What was initially a simple podiatric issue now required a coordinated approach with Billy’s primary care physician to get the infection managed ASAP. Depending on the severity of the infection, treatment ranges from antibiotic management at home to IV antibiotics with a hospital stay to manual debridement of the area (in hospital) and more.

Treatment

Billy ended up being admitted to hospital and treated, where he spent a few days to get the osteomyelitis (and the ingrown nail) under control. He had very close monitoring, as with osteomyelitis there is always a range of other risk factors, including serious ones like sepsis.

We didn’t end up seeing Billy again until several weeks later after the infection had cleared, and the toe was showing good signs of healing. We spoke to Billy about what the bigger picture looks like for his ingrown toenail, given this was not the first time this toe had had an ingrown toenail – he had been experiencing ingrown nails on and off again for almost a decade now.

We agreed that once the toe had fully healed and he was in the clear (so that it would be safe to do so), we would perform a partial nail avulsion (with a chemical matrixectomy) as a permanent solution to Billy’s ingrown nail to help eliminate the risk of this situation arising again in the future – as well as saving himself the hassle of periodically dealing with the pain and discomfort of ingrown nails.

Key Takeaways: Identifying Signs and Symptoms of Osteomyelitis

Recognising the signs and symptoms of osteomyelitis early can be crucial for timely treatment and prevention of more serious complications. Potential signs of osteomyelitis may include:

• Persistent pain: unlike typical discomfort from an ingrown toenail, the pain associated with osteomyelitis can be persistent and is less likely to improve with usual care methods such as soaking or wearing wider shoes.
• Increased swelling and redness: look for swelling and redness that extends beyond the area immediately surrounding the toenail. This can indicate that the infection has spread deeper.
• Warmth: an area that feels unusually warm to the touch (compared to surrounding tissues) might suggest an underlying infection like osteomyelitis.
• Fever or chills: systemic symptoms such as fever or chills, while less common, can occur if the infection is severe and has begun to affect the body more broadly.
• Fatigue: feeling unusually tired or generally unwell can be a sign of your body fighting an infection.
• Non-healing wound: if you have an open wound near the ingrown toenail that doesn’t seem to heal or continuously exudes pus, this could be a sign of a deeper infection impacting the bone.
• Restricted movement: if the infection is near a joint, or the pain is so severe that it limits movement in your toe or foot, this could also be a red flag for osteomyelitis.
• Night pain: experiencing increased pain at night or pain that wakes you from sleep can also be characteristic of bone infections.

These symptoms warrant immediate medical attention, particularly if they persist or worsen despite taking care of the initial cause, such as an ingrown toenail. Early diagnosis and treatment are vital to managing osteomyelitis effectively and preventing further health complications. If you experience any of these symptoms, we recommend seeing your podiatrist or doctor.