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Nail Bed Lacerations
From WikiSM
Contents
Other Names
- Nailbed lac
- Nailbed Laceration
- Finger nail laceration
- Toe nail laceration
- Nailbed avulsion
Background
- This page refers to lacerations of the Fingernail and Toenail
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
- Distal Phalanx Fracture of Hand
- More than 50% of fingertip nailbed injuries have an associated tuft fracture[3]
- Distal Phalanx Fracture of Toe
- Subungual Hematoma
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
- Fractures
- Dislocations
- Tendinopathies
- Ligament Injuries
- Neuropathies
- Arthropathies
- Nail Bed Injuries
- Pediatric Considerations
- Other
Differential Diagnosis Foot Pain
- Fractures & Osseous Disease
- Traumatic/ Acute
- Stress Fractures
- Other Osseous
- Dislocations & Subluxations
- Muscle and Tendon Injuries
- Ligament Injuries
- Plantar Fasciopathy (Plantar Fasciitis)
- Turf Toe
- Plantar Plate Tear
- Spring Ligament Injury
- Neuropathies
- Mortons Neuroma
- Tarsal Tunnel Syndrome
- Joggers Foot (Medial Plantar Nerve)
- Baxters Neuropathy (Lateral Plantar Nerve)
- Arthropathies
- Hallux Rigidus (1st MTPJ OA)
- Gout
- Toenail
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin's Disease)
- Calcaneal Apophysitis (Sever's Disease)
- Freibergs Disease (Avascular Necrosis of the Metatarsal Head)
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
- Standard Radiographs Hand or Standard Radiographs Foot
- Evaluate for associated fracture
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
- In the presence of a subungual hematoma >50% of the nail, some physicians recommend removing the nail and exploring for lacerations
- 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
- Distal Phalanx Fracture
- Hook Nail
- Split Nail
See Also
External
- Sports Med Review Hand Pain: https://www.sportsmedreview.com/by-joint/hand/
- Sports Medicine Review Foot Pain: https://www.sportsmedreview.com/by-joint/foot/
References
- ↑ 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.
- ↑ 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.
- ↑ 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
- ↑ 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.
- ↑ 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
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Last edited:
16 October 2022 00:22:12
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