10.09 Foreign Body Beneath Nail
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agk's Library of Common Simple Emergencies

Presentation
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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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img/cse1009a.gif

img/cse1009b.gif

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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