Nail Bed Laceration

CHAPTER 146


Nail Bed Laceration


Presentation


The patient has either cut into his nail with a sharp edge or crushed his finger (commonly in a door). With shearing forces, the nail may be avulsed from the nail bed to varying degrees, and there may be an underlying bony injury.


What To Do:


image Provide appropriate tetanus prophylaxis (see Appendix H).


image Obtain radiographs of any crush injury. Distal tuft fractures are common with these injuries.


image Complex crush injuries or injuries resulting in significant tissue loss or deformity require specialty consultation with a hand surgeon.


image A small, stable laceration through the nail, with minimal wound separation, can simply be cleansed and sealed with tissue adhesive (Dermabond).


image With a larger or more complicated laceration through the nail, remove the entire nail to allow suturing of the nail as follows:


image Perform a digital block for anesthesia (see Appendix B).


image A bloodless field may need to be established using a finger tourniquet.


image Use a straight hemostat or periosteal elevator to separate the nail from the nail bed (Figure 146-1). Keep instrument pointed toward the nail plate and not toward the nail bed, to prevent further injury.


image


Figure 146-1 Separate nail from nail bed using a straight hemostat.


image Cleanse the wound thoroughly with saline.


image Suture with a fine absorbable material (6-0 or 7-0 Vicryl or Dexon) (Figure 146-2).


image


Figure 146-2 The nail bed can be repaired after it has been fully exposed.


image Replace the nail back into its normal anatomic position, as noted below.


image When a crush injury results in open hemorrhage from under the fingernail, manage as follows:


image Perform a digital block for anesthesia (see Appendix B).


image The nail must then be completely elevated to allow proper inspection of the damaged nail bed.


image A bloodless field may need to be established with a finger tourniquet to help visualization.


image Angulated fractures need to be reduced (see Chapter 111).


image Large nail bed lacerations should be sutured with a fine absorbable suture (6-0 or 7-0 Vicryl or Dexon). Small lacerations with minimal wound edge separation do not require suturing.


image An intact nail should be cleaned and reinserted for protection and proper tissue alignment, or an alternative nail bed dressing can be applied (see Chapter 138).


image Tissue adhesive can be used to bond the nail to the nail bed and seal open spaces or defects in the nail (see Chapter 138). Cover with an appropriate fingertip dressing.


image Inform the patient that a new nail will slowly push off the replaced nail or artificial stent.


What Not To Do:


image Do not use nonabsorbable sutures to repair the nail bed. The patient will be put through unnecessary suffering when the sutures are removed.


image Do not place a dressing that requires removal onto an exposed nail bed. Any such dressing will adhere tenaciously to the nail bed and will be extremely painful to remove (even after a short period of time).


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Aug 11, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Nail Bed Laceration

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