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Updated: May 16 2021

Nail Bed Injury

Images avulsion.jpg
  • summary
    • Nail Bed Injuries are the result of direct trauma to the fingertip and can be characterized into subungual hematoma, nail bed laceration, or nail bed avulsion.
    • Diagnosis is made by careful inspection of the nail bed integrity.
    • Treatment depends on severity and degree of nail bed injury but generally requires removal of the nail and nail bed repair.
  • Epidemiology
    • Incidence 
      • nail bed injuries are included under the umbrella of fingertip injuries
        • finger tip injuries are the most common hand injuries seen in the hospital emergency department
    • Demographics
      • 3:1 male-to-female predominance
  • Etiology
    • Pathophysiology
      • mechanisms of injury include
        • crushing fingertip between two objects
        • catching finger in a closing door
        • saw injury
        • snowblower injury
        • direct blow from a hammer
    • Associated conditions
      • DIP fractures or dislocations
  • Anatomy
    • Nailbed and surrounding tissue
      • perionychium
        • nail
        • nailbed
        • surrounding skin
      • paronychium
        • lateral nail folds
      • hyponychium
        • skin distal distal and palmar to the nail
      • eponychium
        • dorsal nail fold
        • proximal to nail fold
      • lunula
        • white part of the proximal nail
      • matrix
        • sterile
          • soft tissue deep to nail
          • distal to lunula
          • adheres to nail
        • germinal
          • soft tissue deep to nail
          • proximal to sterile matrix
          • responsible for most of nail development
          • insertion of extensor tendon is approximately 1.2 to 1.4 mm proximal to germinal matrix
  • Presentation
    • Symptoms
      • pain
    • Physical exam
      • examine for subungual hematoma
      • inspect nail integrity
  • Imaging
    • Radiographs
      • recommended
        • AP, lateral and oblique of finger
          • to rule out fracture of distal phalanx
  • Subungual Hematoma
    • Most commonly caused by a crushing-type injury
      • causes bleeding beneath nail
    • Treatment
      • drainage of hematoma by perforation
        • indications
          • less than 50% of nail involved
        • techniques
          • puncture nail using sterile needle
          • electrocautery to perforate nail
      • nail removal, D&I, nail bed repair
        • indications
          • > 50 % nail involved
        • technique
          • nail bed repair (see techniques)
  • Nail Bed Lacerations
    • Laceration of the nail and underlying nail bed
      • usually present with the nail intact and a subungual hematoma greater than 50% of nail surface area
    • Treatment
      • nail removal with D&I, nail bed repair
        • indications
          • most cases
        • modalities
          • tetanus and antibiotic prophylaxis
  • Avulsion Injuries
    • Avulsion of nail and portion of underlying nail bed
    • Mechanism
      • usually caused by higher energy injuries
    • Associated conditions
      • commonly associated with other injuries including
        • distal phalanx fracture
          • if present reduction is advocated
    • Treatment
      • nail removal, nail bed repair, +/- fx fixation
        • indications
          • avulsion injury with minimal or no loss of nail matrix, with or without fracture
        • technique
          • always give tetanus and antibiotics
          • fracture fixation depends on fracture type
      • nail removal, nail bed repair, split thickness graft vs. nail matrix transfer, +/- fx fixation
        • indications
          • avulsion or crush injury with significant loss of nail matrix
        • technique
          • always give tetanus and antibiotics
          • nail matrix transfer from adjacent injured finger or nail matrix transfer from second toe
          • fracture fixation depends on fracture type
  • Techniques
    • Nail bed repair
      • nail removal
        • soak nail in Betadine while repairing nail bed
      • nail bed repair
        • repair nail bed with 6-0 or smaller absorbable suture
        • RCT has demonstrated quicker repair time using 2-octylcyanoacrylate (Dermabond) instead of suture with comparable cosmetic and functional results
      • splint eponychial fold
        • splint eponychial fold with original nail, aluminum, or non-adherent gauze
  • Complications
    • Hook nail
      • caused by advancement of the matrix to obtain coverage without adequate bony support
        • Treatment
          • remove nail and trim matrix to level of bone
    • Split nail
      • caused by scarring of the matrix following injury to nail bed
        • Treatment
          • excise scar tissue and replace nail matrix
            • graft may be needed
  • Prognosis
    • Early treatment of acute injuries results in the best outcomes with minimal morbidity
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