From the Guidelines
Proximal fingernail avulsion management should prioritize immediate wound care, careful repair, and prevention of infection to minimize morbidity and mortality, and improve quality of life. The management of proximal fingernail avulsion involves several key steps, including:
- Cleaning the wound thoroughly with sterile saline or mild antiseptic solution to remove debris and reduce infection risk, as suggested by general medical principles and not explicitly outlined in 1 or 1.
- Controlling bleeding with gentle pressure.
- For partial avulsions, carefully repositioning the nail plate to serve as a natural biological dressing, which protects the nail bed and guides regrowth.
- For complete avulsions, if the nail is intact, cleaning it and reinserting it into the nail fold, or considering using a non-adherent dressing or artificial nail substitute if the original nail is damaged or missing.
- Applying antibiotic ointment, such as bacitracin or polysporin, to prevent infection, although the specific choice of antibiotic may depend on the severity of the avulsion and the presence of any underlying infections, as hinted at in 1 for grade 2 treatment.
- Securing the repositioned nail or substitute with sutures (6-0 absorbable) or adhesive strips, and bandaging the finger with sterile gauze.
- Prescribing oral antibiotics, such as cephalexin 500mg four times daily for 5-7 days, if there's significant contamination or crush injury, as would be considered in the management of grade 2 or higher reactions 1.
- Managing pain with acetaminophen or NSAIDs, and administering tetanus prophylaxis if needed.
- Elevating the hand and advising the patient to limit finger use during healing, with follow-up within 48-72 hours to check for infection, as part of standard wound care practices. Complete nail regrowth typically takes 3-6 months, and patients should be informed that minor nail deformities may occur despite proper management. It's essential to note that while 1 and 1 provide guidelines for the management of dermatological toxicities related to anticancer agents, including nail avulsion, the specific management of proximal fingernail avulsion may require a more individualized approach, taking into account the severity of the injury and the patient's overall health status.
From the Research
Proximal Finger Nail Avulsion Management
- The management of proximal finger nail avulsion involves various techniques, including replacement of amputated parts, full and partial thickness nail matrix grafts, composite grafts, and rotation of nail matrix flaps 2.
- Surgical nail avulsion is a frequently undertaken procedure that may be useful for diagnostic or therapeutic purposes, such as exploration of the nail bed, nail matrix, and nail folds, or treatment of onychocryptosis, warts, onychomycosis, and chronic paronychia 3.
- The procedure can be performed using different methods, including the distal approach, and may involve the use of local anesthesia with or without epinephrine 3.
- A new perspective on partial nail avulsion suggests the use of an 11 no. surgical blade instead of nail clippers to minimize trauma to the nail bed and reduce downtime post-procedure 4.
- Nail avulsion is an often over-simplified procedure with a multitude of uses and variations in technique, and can be used to manage various nail conditions when performed with intention and skill 5.
- In cases of acute fingertip injuries with nail bed trauma, management may require specialist hand surgery, but many cases can be managed in emergency departments by emergency nurses with knowledge of anatomy, physiology, and treatment options 6.