II. Causes: High force crush or Laceration injury

  1. Machine press
  2. Rotary saw

III. Associated Conditions

  1. Large Subungual Hematomas (>50% of nail bed)
  2. Distal Tuft Fracture
    1. Antibiotics are controversial (despite this being an open Fracture)

IV. Imaging

  1. XRay AP, lateral and Oblique XRay of digit
    1. Assess for distal Tuft Fracture

V. Management: Nail Bed Laceration Repair

  1. Repair Indications
    1. Subungual Hematoma >50% of nail bed AND
    2. Nail detached or surrounding tissue disrupted (especially at proximal nail at the germinal matrix)
  2. Alternatives to nail bed repair
    1. Indicated if <50% Subungual Hematoma or nail firmly attached and no nail matrix disruption
    2. Consider Nail Trephination for Subungual Hematoma
  3. Anesthesia
    1. Digital Nerve Block
  4. Hemostasis: Apply Tourniquet at digit base
    1. Clamp 1/4 inch Penrose drain at base of finger (or use commercial device such as T-Ring or Tournicot)
  5. Repair
    1. Remove nail in normal fashion, attempting to keep intact for later Splinting
    2. Suture nail bed with Absorbable Suture (e.g. Chromic 6-0)
      1. Use as little Suture as possible (more Suture, more scarring, less chance of nail adherance to the nail bed)
      2. Suture from proximal to distal due to the nail bed friability
    3. Alternatively, Tissue Adhesive has been used in small studies to close nailbed Lacerations with similar outcomes
      1. Strauss (2008) J Hand Surg Am 33(2):250-3 +PMID:18294549 [PubMed]
  6. Nail Replacement
    1. See Nail Replacement for techniques
    2. Replace nail to serve as splint, protect the nail bed and stent the eponychial fold
    3. Avoid using artificial nail splints due deformity risk and infection
    4. Nail Replacement after nail bed repair was associated with increased infection risk and delayed healing in children
      1. Miranda (2012) Plast Reconstr Surg 129(2):394e-396e [PubMed]
    5. Bandage if Nail Replacement not possible
      1. Apply Bacitracin and petroleum gauze over exposed nail
      2. Bandage may be left in place for up to 1 week (change dressing if becomes wet)

VI. Management: Indications for Orthopedic Consultation

  1. Distal tip amputation (risk of hook nail)

VII. References

  1. Brandenburg (1996) Consultant p.331-340
  2. Calmbach (1996) Lecture in Minneapolis
  3. Dvorak (1996) Lecture in Minneapolis
  4. Lillegard (1996) Lecture in Minneapolis
  5. Lin and Lin in Herbert (2014) EM:Rap 14(11): 8-10
  6. Wang (2001) Am Fam Physician 63(10):1961-66 [PubMed]

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