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http://upload.orthobullets.com/topic/6109/images/nail avulsion.jpg
http://upload.orthobullets.com/topic/6109/images/fingertip.jpg
http://upload.orthobullets.com/topic/6109/images/nailbedfxapx1600.jpg
http://upload.orthobullets.com/topic/6109/images/tx of subungual hematoma.jpg
http://upload.orthobullets.com/topic/6109/images/nail.jpg
Introduction
  • Nail bed injuries are the result of direct trauma to the fingertip. Injury types include 
    • subungual hematoma (details below)
    • nail bed laceration 
    • nail bed avulsion 
  • Epidemiology
    • 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 
  • 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 
  • Prognosis
    • early treatment of acute injuries results in the best outcomes with minimal morbidity
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
 

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