Management of Nail Bed Injuries
The standard treatment for nail bed lacerations 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 Indications for Nail Removal
- Nail removal is indicated when there is severe pain, pressure hematoma under the nail, or subungual abscess formation 1, 2
- Nail removal is necessary to properly visualize and repair underlying nail bed lacerations 1
- Severe and/or painful lesions that significantly impact daily activities require immediate nail removal 1, 2
Treatment Protocol
Initial Management
- Carefully remove the nail to expose the nail bed laceration, allowing for proper visualization and repair 1
- Thoroughly clean the nail bed during the procedure to prevent infection and promote healing 1, 3
- Obtain bacterial cultures if infection is suspected 1, 2
- Repair the nail bed laceration meticulously to prevent deformities 1, 3
Infection Management
- Treat any identified infection promptly with appropriate topical/oral antibiotics and antiseptics 1
- Use antibiotics with anti-staphylococcus aureus and gram-positive coverage when infection is suspected 1
- Consider mid to high potency topical steroid ointment applied to nail folds twice daily for edema and pain 1
- Daily dilute vinegar soaks may help reduce inflammation 1
Post-Repair Management
- Regular nail trimming is necessary until the nail plate grows reattached 1, 2
- Monitor for complications such as infection, secondary necrosis, and wound breakdown 3
- Fixation of associated bony injuries is important as the distal phalanx closely underlines the nail bed and provides physical support 3
Special Considerations
- Associated injuries to the fingertip complex (skin, soft tissue, distal phalanx) must be addressed concurrently 3
- Correction of soft tissue injuries may require flaps or grafts in more complex cases 3
- Repair or replacement of the nail plate should be done within the first 24 hours for optimal results 3
- Crush or avulsion injuries tend to have poorer outcomes and may require more extensive management 4
Pitfalls to Avoid
- Failing to remove the nail when indicated can lead to chronic onycholysis and persistent subungual hyperkeratosis 1, 2
- Inadequate cleaning and debridement of the nail bed can lead to complications and poor healing 1, 2
- Underestimating the extent of nail bed injury after blunt trauma can result in inadequate treatment 5
- Delayed treatment may necessitate secondary reconstruction of the nail bed, which often gives unpredictable results 5
- Nail bed injuries with associated fractures of the distal phalanx have higher complication rates and may require antibiotic prophylaxis 6