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Nail Bed Lacerations

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Other Names

  • Nailbed lac
  • Nailbed Laceration
  • Finger nail laceration
  • Toe nail laceration
  • Nailbed avulsion

Background

History

Epidemiology

  • Pediatrics
    • Account for 15-24% of fingertip injuries[1]

Pathophysiology

Illustration of the fingernail anatomy[2]
  • General
    • Laceration to nail bed often associated with other injuries
    • May involve only nail, frequently involves nail bed as well
    • Due to direct trauma (i.e. crush, cutting, etc)
  • Types
    • Simple lacerations
    • Stellate lacerations
    • Crush injuries

Associated Conditions

Pathoanatomy

  • Nail Bed Anatomy and terminology
    • Perionychium: includes the nail, nailbed, and surrounding skin
    • Paronychium: includes the lateral nail folds
    • Hyponychium: skin distal and palmar to the nail
    • Eponychium: includes the dorsal nail fold and proximal to nail fold
    • Lunula: white part of the proximal nail

Risk Factors

  • Unknown

Differential Diagnosis

Differential Diagnosis Hand Pain

Differential Diagnosis Foot Pain


Clinical Features

  • History
    • The patient will describe some form of trauma
    • Patient will endorse pain, swelling, bleeding, deformity
    • Their pay may limit full extension of the affected digit
    • Important to clarify hand dominance, occupation, hobbies, etc
  • Physical Exam: Physical Examination Hand or Physical Exam Foot
    • The patient will have laceration to nail bed, frequently with active bleeding
    • Other soft tissue or osseus injuries may also be apparent
    • Important to document that flexion and extension of the digit are intact

Evaluation


Classification

  • Simple: No bony injury
  • Complex: Involves fracture

Management

Nonoperative

  • Indications
    • Most cases
  • Digital Nerve Block
    • Should be utilized for all procedures
  • Exploration for lacerations
    • In the presence of a subungual hematoma >50% of the nail, some physicians recommend removing the nail and exploring for lacerations
      • This is controversial and likely unnecessary
    • In the presence of partially avulsed nail plate that remains attached to nail matrix, removal is probably not necessary
  • Procedure: Nail Bed Repair
    • Remove the nail plate, evaluate for nail bed injuries and do a primary repair with sutures
    • Remove the nail plate, evaluate for nail bed injuries, suture an artificial spacer under the eponychial fold
    • Do nothing may be an option if the injury is small enough with healing by secondary intention
    • Consider use of medical adhesive to repair nail bed
  • Adhesive Glue Technique
    • Brands include dermabond,
    • Advantages: speed of repair
    • Likely appropriate, effective for smaller or simple lacerations[4]
  • Tetanus Booster
    • Provide as indicated
  • Antibiotic Prophylaxis
    • Indicated depending on mechanism of injury
    • Animal and human bites: Augmentin or non-penicillin alternative
    • Crush injuries: 1st gen cephalosporin
    • “Open fractures”, i.e. associated tuft fracture with nailbed injury: 1st gen cephalosporin
      • Note that this is somewhat controversial but still commonly practiced
      • Metcalf et al: no difference in infection rate, osteomyelitis between prophylaxis group and no prophylaxis[5]

Operative

  • Consider consultation if
    • Fingertip amputations
    • Phalanx fractures that are displaced or complicated
    • Injuries with significant damage to the nail fold
  • Indications
    • Unknown

Rehab and Return to Play

Rehabilitation

  • No clear guidelines

Return to Play/ Work

  • No clear guidelines

Complications and Prognosis

Prognosis

  • Unknown

Complications


See Also


References


  1. Al-Qadhi S, Chan KJ, Fong G, et al. Management of uncomplicated nail bed lacerations presenting to a children's emergency department. Pediatr Emerg Care. 2011;27:379–383.
  2. Patel L. Management of Simple Nail Bed Lacerations and Subungual Hematomas in the Emergency Department. Pediatric Emergency Care. 2014; 30 (10): 742-745. doi: 10.1097/PEC.0000000000000241.
  3. George A, Alexander R, Manju C. Management of Nail Bed Injuries Associated with Fingertip Injuries. Indian J Orthop. 2017;51(6):709-713. doi:10.4103/ortho.IJOrtho_231_16
  4. Edwards, Sarah, and Leesa Parkinson. "Is fixing pediatric nail bed injuries with medical adhesives as effective as suturing?: a review of the literature." Pediatric emergency care 35.1 (2019): 75-77.
  5. Metcalfe D, Aquilina AL, Hedley HM. Prophylactic antibiotics in open distal phalanx fractures: systematic review and meta-analysis. J Hand Surg Eur Vol. 2016;41(4):423-430. doi:10.1177/1753193415601055
Created by:
John Kiel on 1 September 2019 22:25:46
Authors:
Last edited:
14 March 2022 11:10:16
Categories:
Lower Extremity | Trauma | Finger | Foot | Upper Extremity | Acute