Nail Bed Injury

Author: Tracy Jones

Topic updated on 02/24/13 1:55pm

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
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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Qbank (2 Questions)

TAG

(OBQ11.74) A 7-year-old boy sustains a ring finger injury after falling from his bike. The fingernail has been torn transversely beneath the eponychium and the surgeon has removed the nail as shown in Figure A. Radiographs are shown in Figure B. What is the next best step in management? Topic

Review Topic

FIGURES: A

1. Irrigation and debridement with alumafoam placement and immobilization
2. Irrigation and debridement followed by percutaneous pinning and immobilization
3. Irrigation and debridement followed by reduction, nail bed repair and immobilization
4. Betadine soaks at home three times daily with intermittent alumafoam splint placement and immobilization
5. Alumafoam splint placement and immobilization

PREFERRED RESPONSE ▶

DISCUSSION: The clinical presentation is consistent with a physeal separation and a nail bed injury. This is also called a Seymour fracture which is a juxta-epiphyseal fracture of the distal phalanx. Treatment of a nail bed avulsion and physeal separation is irrigation and debridement, physeal reduction, nail bed repair and immobilization. The primary goals are to achieve a stable, viable nail and good cosmetic results.

Inglefield at al retrospectively reviewed 19 children with 22 nail bed injuries. Early operative repair led to good to excellent results in 91% of patients. They concluded that repair of the nail bed at the time of injury is superior to secondary correction.

Fassler reviewed fingertip injuries, providing recommendations for treatment based on degree of soft tissue loss, bone exposure, feasibility for flap coverage and the presence or absence of mitigating systemic conditions. He also concluded that the outcome of nail bed injuries is dependent on the severity of injury to the germinal matrix.

Illustration A shows the makeup of the terminal phalanx. Illustration B shows nail bed repair with suture.

Illustrations: A

REFERENCES:

1. Inglefield CJ, D'Arcangelo M, Kolhe PS. Injuries to the nail bed in childhood. J Hand Surg Br. 1995 Apr;20(2):258-61. PMID:7797986 (Link to Abstract)

2. Fassler PR. Fingertip injuries: evaluation and treatment. J Am Acad Orthop Surg. 1996 Jan;4(1):84-92. PMID:10795040 (Link to Abstract)

Question Authors:

Terrill Julien MD, John Badylak MD, Dave Marcu MD,

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TAG

(OBQ09.14) Repair of a nailbed injury with 2-octylcyanoacrylate (Dermabond) provides what distinct advantage over standard suture repair? Topic

Review Topic

1. Better ultimate cosmesis
2. Better functional outcome
3. Faster procedure
4. Less pain
5. Lower infection rate

PREFERRED RESPONSE ▶

DISCUSSION: Octylcyanoacrylate (Dermabond) has been found to be a viable method in nailbed repair, and has the advantage of being a faster procedure.

Strauss et al performed a level 1 randomized trial of 2-octylcyanoacrylate (Dermabond) versus suture repair of nailbed injuries. They found the only significant difference was that 2-octylcyanoacrylate had a shorter procedure time. All other indices were similar.

Richards et al provide a description of their technique using dermabond to secure the nail following a nailbed repair. They found good results with no complications in their cohort of 22 patients, and recommend it as a technique.

Incorrect Answers
Answer 1,2,4,5: There is no difference in these outcomes when comparing 2-octylcyanoacrylate (Dermabond) versus suture repair

REFERENCES:

1. Strauss EJ, Weil WM, Jordan C, et al: A prospective, randomized, controlled trial of 2- octylcyanoacrylate versus suture repair for nail bed injuries. J Hand Surg Am 2008;33:250- 253 PMID:18294549 (Link to Abstract)

2. Richards AM, Chrick A, Cole RP: A novel method of securing the nail following nail bed repair. Plast Reconstr Surg 1999;103:1983-1985 PMID:10359264 (Link to Abstract)

Question Authors:

Greg Galano MD, Patrick McCulloch MD, Ben Taylor MD,

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ABOS II: Nail Bed Injury

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Level of Evidence 4 (Case Series)

Inglefield CJ, D'Arcangelo M, Kolhe PS. Injuries to the nail bed in childhood. J Hand Surg Br. 1995 Apr;20(2):258-61. PMID:7797986 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Fassler PR. Fingertip injuries: evaluation and treatment. J Am Acad Orthop Surg. 1996 Jan;4(1):84-92. PMID:10795040 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Strauss EJ, Weil WM, Jordan C, et al: A prospective, randomized, controlled trial of 2- octylcyanoacrylate versus suture repair for nail bed injuries. J Hand Surg Am 2008;33:250- 253 PMID:18294549 (Link to Abstract)
Richards AM, Chrick A, Cole RP: A novel method of securing the nail following nail bed repair. Plast Reconstr Surg 1999;103:1983-1985 PMID:10359264 (Link to Abstract)

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Nail Bed Injury

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