10.04 Finger or toenail avulsion
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agk's Library of Common Simple Emergencies


Presentation
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The patient may have had a blow to the nail; 
the nail may have been torn away by a fan blade 
or other piece of machinery; or a long hard 
toenail may have caught on a loop of a shag 
carpet or other fixed object and been pulled 
off the nailbed. The nail may be completely 
avulsed, partially held in place by the nail 
folds, or adhering only to the distal nail bed. 
On occasion, an exposed nailbed will have a 
pearly appearance with minimal bleeding making 
it seem as if the nail is still in place when 
actually it has been completely avulsed.

What to do:
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- Obtain x rays if there was any crushing or 
    high velocity shearing force involved.
- Perform a [digital block] to anesthetize the 
    entire nailbed.
- Cleanse the nailbed with normal saline and 
    remove any loose cuticular debris. Although 
    it is acceptable simply to cover the 
    nailbed with a non-adherent dressing, the 
    patient is usually more comfortable with a 
    clean nail or surrogate in place while a 
    new nail grows in. No dressing is truely 
    non-adherent over an exposed naibed. If the 
    nail or artificial stent is not used, then 
    bring the patient back for an early 
    dressing change in one day to prevent 
    adherence.
- If the nail is still tenuously attached, 
    remove it by separating it from the nail- 
    fold using a hemostat. Cleanse the nail 
    thoroughly with normal saline, cut away the 
    distal free edge of the nail and remove 
    only loose cuticular debris.
- Inspect the nailbed for lacerations and if 
    present carefully reapproximate with fine 
    (6-0 or 7-0) absorbable sutures.
- Reduce any displaced or angulated fractures 
    of the distal phalynx. If a stable 
    reduction cannot be obtained, consult an 
    orthopedic surgeon for possible pinning.
- Reinsert the nail under the eponychium and 
    apply a fingertip [dressing].
- If the nail does not fit tightly under the 
    eponychium, it can be sutured in place at 
    its base.
- If the nail is missing, badly damaged or 
    contaminated, replace it with a substitute. 
    An artificial nail can be cut out of the 
    sterile aluminum foil found in a suture 
    pack or can be cut from a sheet of vaseline 
    gauze. Insert this stent under the 
    eponychium as you would the nail and apply 
    a fingertip dressing after it is in place.
- Leave these stents in place until the nailbed 
    hardens and the stent separates 
    spontaneously.
- Dressings should be changed every three to 
    five days.
- If the wound was contaminated, tissue 
    macerated, pr patient immunocompromised, 
    prescribe three or four days of a first 
    generation cephalosporin as prophylaxis. 
    Fractures of the distal phalynx do not 
    always require antibiotics however.

What not to do:
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- Do not dress an exposed nailbed with an 
    ordinary gauze dressing. It will adhere to 
    the nailbed and require lengthy soaks and 
    at times an extremely painful removal.
- Do not ignore nailbed lacerations or 
    fractures of the distal phalanx. The new 
    nail can become deformed or ingrown 
    wherever the bed is not smooth and 
    straight.
- Do not debride any portion of the nailbed, 
    sterile matrix or germinal matrix.

Discussion:
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Although the eponychium is unlikely to scar to 
the nailbed unless there is infection, 
inflammation, or considerable tissue damage, 
separating the eponychium from the nail matrix 
by reinserting the nail or inserting an 
artificial stent helps to prevent synechia and 
future nail deformities from developing. The 
patient's own nail is also his most comfortable 
dressing. Minimally traumatized avulsed nails 
can actually grow normally if carefully 
replaced in their proper anatomic position. A 
gauze stent left in the nail sulcus will be 
pushed out as the new nail grows. Complete 
regrowth of an avulsed nail usually requires 
four to five months at one milimeter per week.

Illustration
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img/cse1004.gif

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