II. Management: Nail Injury

  1. See Nail Injury
  2. Retain the native nail
    1. Acts as a splint 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]
  3. Reattach partially avulsed or fully avulsed nails
    1. Option 1: Tack down nail edge at each Paronychial fold
      1. Hold nail in place with a 1-2 Sutures through nail and the adjacent lateral nail folds (Paronychial fold)
      2. Risk of nail sliding out from the eponychial fold (proximally) and Paronychial folds (laterally)
    2. 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
  4. Repair nail bed if indicated
    1. See Nail Bed Laceration
    2. Indications
      1. Subungual Hematoma >50% of nail bed AND
      2. Nail detached or surrounding tissue disrupted (especially at proximal nail at the germinal matrix)
    3. Repair
      1. Remove nail attempting to keep intact for later Splinting
      2. Use Absorbable Suture (e.g. Chromic 6-0)
      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 [PubMed]
    4. Nail Replacement
      1. Replace nail to serve as splint, protect the nail bed and stent the eponychial fold
      2. Avoid using artificial nail splints due deformity risk and infection
      3. 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]

III. Management: General principles

  1. Control bleeding
    1. See Finger Wound Hemostasis
  2. Control pain
    1. See Digital Block (Metacarpal Block)
  3. Preserve finger length
    1. Critical for thumb, index, and middle finger function
  4. Avoid tight, excessive tension of a finger tip closure
    1. Excessive skin tension at the finger tip is a risk for hook nail
    2. Ronger end of distal phalanx if it protrudes beyond soft tissue
    3. Healing by Secondary Intention is preferred if skin is inadequate to close wound without tension
  5. Treatment of finger injury is directed at coverage
    1. Do not close major wounds by secondary intention
      1. Epithelization is delayed 12 weeks
      2. Results in thin, tender overlying skin
  6. Repair tendon injuries
    1. Consult orthopedics if unable to repair injury
    2. Protect wound site if repair at other facility
      1. See Wound Dressing for Transport

IV. Management: Types of Closure

  1. Simple
    1. Keep scar line on dorsal surface as much as possible
      1. Prevents a tender scar
    2. Never trim dog ears (may compromise healing)
  2. Epithelialization (Healing by Secondary Intention)
  3. Free Grafts
  4. Flap Grafts
    1. Occassionally used by experienced surgeon)
    2. Indicated when subcutaneous tissue needed
      1. Grafting over bone or tendon

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