The patient has either cut into his nailbed with a sharp
edge or crushed his finger. With shearing forces, the nail
may be avulsed from the nailbed to varying degrees and there
may be an underlying bony deformity.
What to do:
Provide appropriate tetanus prophylaxis.
Obtain x rays of any crush injury or any injury caused by machinery.
Perform a digital block for anesthesia. Use bupivicaine for longer-acting anesthesia if the pain is expected to persist for several more hours.
With a simple laceration through the nail, remove the nail
surrounding the laceration to allow for suturing the
laceration closed:
Use a straight hemostat to separate the nail from the
nailbed.
Use fine scissors to cut away the surrounding nail or remove the entire nail intact for re-insertion after the nailbed is repaired.
Cleanse the wound with saline and suture accurately with a fine
absorbable suture (6-0 or 7-0 Vicryl or Dexon). Close approximation of the nailbed is necessary to prevent nail deformity. Also preserve the skin folds around nail margins.
Apply a nonadherent dressing (e.g., Adaptic gauze) and
antibiotic antiseptic ointment and plan a dressing change
within 24 hours to prevent painful adherence to the
nailbed.
When a crush injury results in open hemorrhage from under
the fingernail, the nail must be completely elevated to
allow proper inspection of the damage to the nailbed. A
bloodless field helps visualization. (A one half-inch
Penrose drain makes a good finger tourniquet. Alternatively, you can put the patient's hand in a sterile glove, cut off the tip and roll down the finger to form a tourniquet.) Angulated fractures need to be reduced and nailbed lacerations should
be sutured with a fine absorbable suture as above. If the nail is intact, it can be cleaned and reinserted for protection as described in "Fingernail or toenail avulsion". If the nail is ruined, place a stent under the eponychium to prevent adhesion to the nail bed.
Do not use non-absorbable sutures to repair the nailbed.
The patient will be put through unnecessary suffering in
order to remove the sutures.
Do not attempt to suture a nailbed laceration through the
nail. It can be done, but precludes the meticulous
approximation necessary for smooth nail regrowth.
Do not do any more than minimal debridement of the nailbed and its surrounding structures. Only clearly devitalized and contaminated tissue should be removed to prevent future nail deformity.
Discussion:
Significant nailbed injuries can be hidden by hemorrhage
and a partially avulsed overlying nail. These injuries must
be carefully repaired to help prevent future deformity of the nail. There are no truly non-adherent dressings for a nailbed, so when it is exposed, arrange to change the dressing in 12 to 24 hours before it adheres to this delicate tissue. Surgical consultation should be obtained when complex nailbed
lacerations involve the germinal matrix under the base of
the nail. Later nail deformity or splitting can sometimes be repaired electively but often it is permanent.
