10.03 Nail Root Dislocation
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agk's Library of Common Simple Emergencies

Presentation
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The patient has caught his finger in a car door 
or dropped a heavy object like a can of 
vegetables on a bare toe, with the edge of the 
can striking the base of the toenail and 
causing a painful deformity. The base of the 
nail will be found resting above the eponychium 
instead of in its normal anatomical position 
beneath. The cuticular line that had joined he 
eponychium at the nail fold will remain 
attached to the nail at ts original position.

What to do:
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- Take an x ray to rule out an underlying 
    fracture (which may require reduction as 
    well as protective splinting.)
- Anesthetize the area using a [digital block].
- Lift the base of the nail off the eponychium, 
    and thoroughly cleanse and inspect the nail 
    bed. Minimally debride loose cuticular 
    tissue and test for a possible [avulsion of 
    the extensor tendon].
- If bleeding is a problem, establish a blood- 
    less field using a Penrose drain to wrap 
    and tourniquet the finger.
- Repair any nailbed lacerations with a fine 
    absorbable suture like 7-0 or 6-0 Vicryl.
- Reinsert the root of the nail under the 
    eponychium.
- Reduce any underlying angulated fracture.
- If the nail tends to drift out from under the 
    eponychium, it can be sutured in place with 
    two 4-0 nylon or polypropylene stiches in 
    the corners.
- Any non-absorbable sutures should be removed 
    after one week.
- Cover the area with a finger tip [dressing] 
    and splint any underlying fracture.
- Provide tetanus prophylaxis.
- Followup should be provided in 3-5 days. 
    Instruct patients to return immediately if 
    there is increasing pain or any other sign 
    of infection.
- Prescribe an analgesic like acetaminophen and 
    hydrocodone.

What not to do:
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- Do not ignore the nail root dislocation and 
    simply provide a finger tip dressing. This 
    is likely to lead to continued bleeding or 
    to a later infection because tissue planes 
    have not been replaced in their natural 
    anatomic position.
- Do not debride any postion of the nailbed, 
    sterile matrix or germinal matrix.

Discussion:
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Because the nail is not as firmly attached at 
the base or lunula as it is to the distal nail 
bed, impact injuries can avulse only the base 
(nail root) leaving it lying on top of the 
eponychium. It may be surprising that this 
injury is often missed but at first glance, a 
dislocated nail can appear to be in place, and 
without careful inspection, a patient can 
return from radiology with negative x rays and 
be treated as if he only had an abrasion or 
contusion. The attachment of the cuticle from 
the nailfold of the eponychium to the base of 
the nail forms a constant landmark on the nail. 
If any nail is showing proximal to this 
landmark it indicates that the nail is not in 
its normal position beneath the eponychium.

Illustration
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img/cse1003.gif

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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