From the Guidelines
Management of a partially avulsed proximal nail with adjacent laceration and fracture should prioritize thorough wound cleaning with simple saline solution, as recommended by the most recent guidelines 1. The initial step involves cleaning the wound with sterile saline solution to prevent infection, as additives such as soap or antiseptics provide no further benefit 1. For the partially avulsed nail, attempt to reposition it if viable, serving as a natural biological dressing, and secure it with adhesive strips or sutures if stable enough. The adjacent laceration should be irrigated thoroughly and closed with 5-0 or 6-0 non-absorbable sutures after ensuring no foreign bodies remain. Key considerations include:
- Thorough wound cleaning with saline solution
- Repositioning and securing the avulsed nail
- Irrigation and closure of the laceration
- Assessment and management of the underlying fracture The underlying fracture should be assessed radiographically to determine if it's stable or displaced. If stable, buddy-taping to an adjacent finger with a dorsal aluminum splint for 3-4 weeks is appropriate. For displaced fractures, orthopedic consultation for possible reduction is necessary. The use of perioperative and postoperative systemic antibiotics, such as cefazolin or clindamycin, is strongly recommended for open fractures 1. Pain management with acetaminophen or NSAIDs, elevation of the extremity to reduce swelling, and scheduling follow-up within 48-72 hours to reassess the wound and nail bed are also crucial. Tetanus prophylaxis should be administered if the patient's immunization status is outdated. Overall, a comprehensive approach addressing the triad of injuries while preserving nail bed anatomy and promoting optimal functional recovery is essential.
From the Research
Management of Partially Avulsed Proximal Nail
- The management of partially avulsed proximal nail with adjacent laceration and fracture requires careful evaluation and treatment to prevent lasting effects on finger function and cosmesis 2.
- A thorough physical examination should be performed to determine the extent of the injury, including a comprehensive neurovascular examination to assess pulp capillary refill and range of motion 2.
- Treatment for nail bed trauma, including subungual hematomas, distal phalanx fractures, and fragmentation or avulsion of the nail bed, may involve exploration and repair, especially if the nail plate is injured or there is a proximal fracture involving the germinal matrix 2, 3.
- Partial nail avulsion may be beneficial in reducing pain and promoting wound healing by decreasing the defect of the nail plate and the injury of the nail bed 4.
- The use of local anesthesia and a tourniquet may be necessary for clinical evaluation and treatment of nail trauma 2.
Treatment Options
- Nail bed lacerations may be repaired using dissolvable suture or octyl-2-cyanoacrylate, and in most cases, there is no need to replace the nail plate or stent the fold 3.
- Subungual hematomas may be treated with simple trephination for pain relief 3.
- Amputations, partial or complete, can be treated with a wide variety of techniques, but many distal injuries can be left to heal by secondary intention with excellent results 3.
- Antibiotic and tetanus prophylaxis may be necessary to prevent infection, especially in cases of crush or avulsion injuries 5.