When should the nail be removed in pediatric patients with nail blunt trauma?

Management of Nail Blunt Trauma in Pediatric Patients

Nail removal is indicated in pediatric patients with blunt trauma when there is severe pain, a pressure hematoma, or a subungual abscess. 1

Assessment of Nail Injuries

• Door crush injuries are the most common mechanism of nail trauma in children (59.5%), with most injuries occurring at home (46.4%) 2
• Simple nail bed laceration with partial avulsion is the most frequent type of nail bed injury (44.4%) in pediatric patients 2
• Blunt trauma to fingertips can easily lead to underestimated nail bed injuries that are more extensive than initially apparent 3

Indications for Nail Removal

Immediate Nail Removal Required:

• Severe and/or painful lesions that significantly impact daily activities 1
• Presence of a pressure hematoma under the nail 1
• Subungual abscess formation 1
• Stellate lacerations or severely crushed nail beds (higher risk of complications) 2

Nail Can Be Preserved When:

• Pain is minimal or manageable 1
• No evidence of pressure hematoma or infection 1
• Simple nail bed injuries without significant displacement 2

Management Protocol

1. Initial Assessment:

   • Evaluate the extent of nail bed injury - remove the nail if the full extent of injury cannot be properly assessed 3
   • Check for associated distal phalanx fractures (presence of fracture increases risk of complications and need for antibiotics) 2

2. When Nail Removal is Performed:

   • Clean the nail bed thoroughly 1
   • Obtain bacterial cultures if infection is suspected 1
   • Treat any identified infection with appropriate topical/oral antibiotics and antiseptics 1
   • Repair the nail bed meticulously to prevent complications 2

3. Post-Removal Care:

   • Regular nail trimming until the nail plate grows reattached 1
   • Monitor for complications such as fingertip sensitivity (5.3%), split nail deformity (5.3%), infection (3.9%), and nonadherence of nail plate (2%) 2

Important Considerations

• Most pediatric nail bed injuries can be repaired by emergency physicians (72.2% in one study) 2
• Thorough initial assessment and meticulous repair are crucial for good functional and cosmetic outcomes 3
• Predictors for complications include stellate lacerations, severely crushed nail beds, and fractures of the distal phalanx 2
• Delayed or inadequate treatment may lead to permanent nail deformities that are difficult to correct with secondary reconstruction 3

Pitfalls to Avoid

• Underestimating the extent of nail bed injury - what appears as a simple subungual hematoma may conceal a more complex nail bed laceration 3
• Failing to remove the nail when indicated can lead to chronic onycholysis and persistent subungual hyperkeratosis 1
• Neglecting to assess for and document associated fractures, which influence both treatment decisions and prognosis 2
• Inadequate cleaning and debridement of the nail bed when nail removal is performed 1