10.09 Foreign Body Beneath Nail

agk’s Library of Common Simple Emergencies

Presentation

The patient complains of a paint chip or sliver under the nail. often he has unsuccessfully attempted to remove the foreign body, which will be visible beneath the nail.

What to do (Paint Chip):

• Without anesthesia, remove the overlying nail by shaving it off with a #15 scalpel blade.
• Cleanse remaining debris with normal saline and trim the nail edges smooth with scissors.
• Provide tetanus prophylaxis if necessary and then dress the area with antibiotic ointment and a bandage.

What to do (Sliver):

• If the patient is cooperative and can tolerate some discomfort, carve through the nail down to the perimeter of the sliver with a #11 blade until the overlying nail falls away. The foreign body can now be cleansed away, antibiotic ointment can be applied to the exposed nailbed, and a Band-Aid dressing can be applied.
• For a more extensive excision of a nail wedge, you will need to perform a digital block.
• Slide small Mayo or iris scissors between the nail and nailbed on both sides of the sliver and cut out the overlying wedge of nail.
• Cleanse any remaining debris with normal saline and trim the fingernail until the corners are smooth.
• Provide tetanus prophylaxis if needed.
• Dress with antibiotic ointment and a bandage. Have the patient redress the area 2-3 times daily until healed, and keep the fingernail trimmed close.

What not to do:

• Do not run the tip of the scissors into the nail bed while sliding it under the fingernail (instead angle the tip up into undersurface of the nail).

Discussion:

It is often not possible to remove a long sliver from beneath the fingernail using the “shaving” technique with a scapel blade, without injuring the nailbed, and causing the patient considerable discomfort. After providing a digital block, it is sometimes possible to remove the sliver by surrounding it with a hemostat that has been slipped between the nail and nailbed and then pulling out the entire sliver, but if any debris remains visible, then the overlying nail wedge should be removed so the nailbed can be thoroughly cleansed. It is usually unwise simply to attempt to pull the foreign body from beneath the nail because some debris usually remains and will most likely lead to a nailbed infection.

Illustration

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from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES ©
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