What is the treatment for a nail bed laceration?

Treatment of Nail Bed Laceration

For nail bed lacerations, the standard treatment involves nail removal, meticulous cleaning and repair of the nail bed, and appropriate management of any associated complications such as infection or hematoma. 1

Assessment and Initial Management

• Nail bed injuries should be thoroughly assessed for severity, presence of subungual hematoma, and potential infection before determining treatment approach 2
• Careful evaluation of the nail, surrounding tissues, and underlying bone is essential as these injuries often involve paraungueal tissues, fingertip, and bone 3

Treatment Protocol for Nail Bed Laceration

Indications for Nail Removal and Repair

• Nail removal is indicated when there is:
  • Severe pain 1
  • Pressure hematoma under the nail 1
  • Subungual abscess formation 1
  • Simple or stellate lacerations of the nail bed 4

Procedural Steps

1. Nail Removal:

   • The nail should be carefully removed to expose the nail bed laceration 1
   • This allows for proper visualization and repair of the underlying laceration 4

2. Nail Bed Repair Options:

   • Traditional suture repair: Using 6-0 chromic sutures for nail bed laceration repair 5
   • 2-octylcyanoacrylate (Dermabond): An efficient alternative to suturing with similar cosmetic and functional outcomes but significantly faster repair time (9.5 vs 27.8 minutes) 5

3. Post-Repair Management:

   • The nail bed must be thoroughly cleaned during the procedure 1
   • Bacterial cultures should be obtained if infection is suspected 1
   • Any identified infection should be promptly treated with appropriate topical/oral antibiotics and antiseptics 1
   • Regular nail trimming is necessary until the nail plate grows reattached 1

Special Considerations

Infection Management

• If pus is present, culture should be obtained and appropriate antibiotics initiated 6
• Antibiotics with anti-staphylococcus aureus and gram-positive coverage are recommended when infection is suspected 6

Pain and Edema Management

• Mid to high potency topical steroid ointment can be applied to nail folds twice daily for edema and pain 6
• Daily dilute vinegar soaks (50:50 dilution) to nail folds twice daily for 10-15 minutes may help reduce inflammation 6

Complications to Monitor

• Potential complications include:
  • Fingertip sensitivity (5.3%) 2
  • Split nail deformity (5.3%) 2
  • Infection (3.9%) 2
  • Nonadherence of the nail plate (2%) 2
  • Hook nail deformity (1%) 2

Pitfalls to Avoid

• Failing to remove the nail when indicated can lead to chronic onycholysis and persistent subungual hyperkeratosis 1
• Inadequate cleaning and debridement of the nail bed can lead to complications 1
• Delay in treatment may result in long-term fingertip deformities and functional deficits 4

Provider Considerations

• Both emergency physicians and specialists can effectively manage uncomplicated nail bed lacerations with similar outcomes 7
• Meticulous initial repair is crucial for good long-term cosmetic and functional results 2