III. Management: Native Nail vs artificial stent

  1. Retain the native nail (best option)
    1. Acts as a splint to hold open eponychial and protects the nail bed
    2. Avoid artificial nail splints due deformity risk and infection (use the native nail instead)
      1. Weinand (2014) World J Surg 38(10): 2574-9 [PubMed]
  2. Native nail not available (lost or destroyed)
    1. Use a nail substitute (e.g. foil from Suture pack cut to size)
      1. Inserted under the eponychial fold to prevent scarring, closure
    2. However, nail stenting has been found to slow healing with higher infection risk
      1. Miranda (2012) Plast Reconstr Surg 129(2): 394e-396e +PMID: 22286484 [PubMed]

IV. Management: Nail Replacement

  1. Reattach partially avulsed or fully avulsed nails
  2. Option 1: Tack down nail edge at each Paronychial fold
    1. Consider pre-drilling holes (e.g. cautery, #18 gauge needle) in a thick nail to allow Suture to more easily pass
    2. Hold nail in place with a 1-2 Sutures through nail and the adjacent lateral nail folds (Paronychial fold)
    3. Risk of nail sliding out from the eponychial fold (proximally) and Paronychial folds (laterally)
  3. Option 2: Transverse figure of eight technique
    1. Indicated for nail reattachment
    2. Soak the nail in warm saline for 15 minutes
    3. Cut two 1 mm wedges into the distal nail edge (similar to the top of a king's crown)
    4. Suture the nail to hold it in place
      1. Place first Suture throw adjacent to one lateral nail edge, from distal to proximal
      2. Pull the Suture from proximal nail edge, across the nail diagonally to distal notch
      3. Thread the Suture around the distal nail to the second notch
      4. Place the second Suture throw from the other lateral nail edge, from distal to proximal
      5. Pull the Suture from the proximal nail edge across the nail diagonally to the start of the Suture
      6. Tie off the Suture
    5. Resources
      1. Closing the Gap: Wound Closure for the Emergency Practitioner
        1. http://lacerationrepair.com/special-situations/nailbed-injuries-part-ii/
    6. References
      1. Bristol (2007) J Hand Surg Am 32(1):124-5 [PubMed]
      2. Memon (2012) Indian J Orthop 46(3): 346–50 [PubMed]
  4. Option 3: Tissue Adhesive
    1. Replace intact nail back within the folds of the fingertip
    2. Dry the edges carefully
    3. Apply Tissue Adhesive at the nail fold edges to secure in place
    4. Lin in Herbert (2015) EM:Rap 15(2): 6-7

V. Management: Subungual Trauma

  1. See Nail Bed Laceration
  2. See Subungual Hematoma
  3. Nail Bed 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)

VI. References

  1. Lin and Lin in Herbert (2014) EM:Rap 14(11): 8-10
  2. Lin, Gajendran and Orman in Herbert (2016) EM:Rap 16(11): 7-8

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