When is splitting the nail bed necessary?

Indications for Splitting the Nail Bed

Splitting or removal of the nail plate is necessary in cases of severe and/or painful nail lesions, when associated with a pressure hematoma or subungual abscess, or for significantly detached nails causing pain or showing signs of infection. 1, 2

Primary Indications for Nail Bed Splitting

• Painful hematoma or subungual abscess

  • When a subungual hematoma causes significant pain
  • When accumulated blood creates pressure on the nail matrix
  • When the hematoma occupies a large portion of the nail bed

• Infection management

  • When infection is suspected beneath a partially detached nail
  • When the space between a partially detached nail and nail bed creates an environment for bacterial growth
  • To allow proper cleaning and culturing of the nail bed

• Significantly detached nails

  • When the nail is partially torn but still attached
  • When the detached portion causes pain or discomfort
  • To prevent further trauma to the nail bed

Clinical Decision Algorithm

1. Assess the nail injury:

   • Determine extent of nail detachment
   • Check for signs of infection (redness, warmth, purulence)
   • Evaluate pain level and functional impairment
   • Assess for subungual hematoma

2. Specific indications for splitting/removal:

   • Grade 2 or higher onycholysis (according to CTCAE v5.0) 1
   • Painful subungual hematoma causing pressure on nail matrix 2, 3
   • Partially torn nail that is significantly detached 2
   • Signs of infection beneath the nail plate 1, 2
   • Subungual abscess formation 1

3. Consider patient-specific factors:

   • Diabetes or immunocompromised status (lower threshold for intervention) 2
   • Oncology patients on taxane therapy with onycholysis 1
   • Presence of distal phalangeal fracture (may require more comprehensive management) 4

Procedure Selection Based on Condition

• For simple subungual hematoma without nail detachment:

  • Nail trephination using electrocautery or hand-held cautery is sufficient 3, 5
  • Complete nail removal is unnecessary for simple subungual hematomas 3

• For partially detached nails:

  • Complete removal if significantly detached or causing pain 2
  • Clean and culture the nail bed after removal 1
  • Apply appropriate antibiotics if infection is suspected 1, 2

• For taxane-induced onycholysis:

  • Partial or total nail avulsion for Grade 2 treatment with painful hematoma or subungual abscess 1
  • Interrupt anticancer treatment for Grade 3 or intolerable Grade 2 reactions 1

Post-Procedure Care

• Clean the nail bed and obtain cultures if infection is suspected 1, 2
• Apply topical antibiotic ointment and sterile, non-adherent dressing 2
• Elevate the foot to reduce swelling 2
• Regularly trim nails until the nail plate grows reattached 1
• Monitor for signs of infection requiring systemic antibiotics 1, 2

Important Caveats and Pitfalls

• Potential complications to avoid:

  • Permanent nail deformity if the matrix is damaged during removal 2
  • Secondary infection if proper sterile technique is not maintained 2
  • Onycholysis becoming permanent if not properly managed 2, 4
  • Delayed diagnosis of malignancy if persistent lesions are not biopsied 2

• Special considerations:

  • Diabetic patients require more vigilant monitoring and earlier intervention 2
  • Avoid surgical procedures in patients with poor circulation without prior vascular evaluation 2
  • Consider early referral to specialists for diabetic patients with nail injuries 2

Remember that prompt decompression of subungual hematomas can significantly reduce pain and prevent further damage to the nail bed and matrix 4. However, patients should be warned that even with appropriate treatment, complications such as onycholysis, transient or permanent nail deformity, and infection are possible 4.