10.06 Nailbed Laceration
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agk's Library of Common Simple Emergencies

Presentation
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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:
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- 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 anti- 
        septic 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:
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- 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:
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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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img/cse1006.gif

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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