Nail bed lacerations

HPI:  
Middle-aged male with no medical history presents to the ED with a laceration to his left middle fingertip.  He was using a circular saw to cut wood this afternoon when he inadvertently cut his left middle finger.  He denies other injuries, and all vital signs are within normal limits.

Exam:
Deep laceration to dorsal surface of distal phalanx on L middle finger involving the lateral nail bed.  Full motor/sensory function is intact.  Cap refill <2 seconds.  Plain films negative for acute fracture/dislocation.  (representative image seen below)

Discussion:
Fingertip injuries are the most common hand injuries seen in the ED, and evidence shows effective early treatment clearly results in best cosmetic and functional outcomes. Special consideration is taken when injury involves the nail bed.

· Germinal Matrix - soft tissue at base of the nail responsible for nail generation/growth.

· Sterile Matrix - soft tissue adherent to underside of the nail plate responsible for nail strength/thickness.

If nail plate is avulsed or subungual hematoma involves >50% of nail bed, then nail should be removed for hematoma evacuation/irrigation.  If underlying laceration involves the germinal or sterile matrix, it should be repaired w/ 6-0 absorbable suture or Dermabond.

Soak nail plate in a povidone iodine solution while performing repair.  Replace the extracted nail plate at completion to splint the eponychial folds and better mold the edges of the repair for optimal healing (can be sutured in place).  Apply a nonadherent dressing and consider a splint to immobilize DIP joint and protect the fingertip.

Management Pearls:
·  Pain control (digital block), update tetanus status, Abx prophylaxis
·  Plain films to rule-out distal phalanx fracture
·  Copious irrigation and close inspection of wound
·  Nail plate removal and/or nail bed repair as indicated
·  Replace nail plate to splint eponychial fold and promote nail growth at germinal matrix
·  Non-urgent orthopedic follow-up as outpatient

 By Dr. Blake Johnson

 
References:
1. Jones, T. Nail Bed Injury [Web log post]. Retrieved 3 Sept 2015, from http://www.orthobullets.com/hand/6109/nail-bed-injury.
2. Strauss EJ, Weil WM, Jordan C, et al. A prospective, randomized, controlled trial of 2-octylcyanoacrylate versus suture repair for nail bed injuries. J Hand Surg [Am]. 2008 Feb. 33(2):250-3.
3. Yallapragada, R. “Nail Bed Laceration Repair.” eMedicine/Medscape, 25 June 2015. Web. Retrieved 3 Sept 2015, from http://emedicine.medscape.com/article/80792-overview.
4. http://www.sawaccidents.com/table-saw-injury-pictures.htm  (image 1)
5. http://www.medicinenet.com/image-collection/fingernail_anatomy_picture/picture.htm  (image 2)