10.06 Nailbed Laceration

agk’s Library of Common Simple Emergencies

Presentation

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.
• Apply a fingertip dressing.

What not to do:

• 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.

Illustration

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from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES ©
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