Should I remove a partially hanging nail after a crush injury with a fracture of the distal phalanx?

Management of Partially Hanging Nail After Crush Injury with Distal Phalanx Fracture

Yes, remove the partially hanging nail to properly assess and repair the underlying nail bed injury, as crush injuries with distal phalanx fractures commonly involve significant nail bed lacerations that are underestimated on initial examination and require direct visualization for adequate treatment. 1

Rationale for Nail Removal

Blunt trauma to the fingertip with distal phalanx fractures frequently causes nail bed injuries that are more extensive than initially apparent during emergency department evaluation. 1 When the nail is removed, the underlying nail bed laceration is often found to be more severe than anticipated, requiring formal repair to prevent long-term complications. 1

Delayed or inadequate treatment of nail bed injuries leads to substantial clinical problems including:

• Nail deformities 1
• Chronic pain 1
• Need for secondary reconstruction with unpredictable results 1
• Infection risk 2
• Physeal arrest (in pediatric cases) 2

Treatment Algorithm

Immediate Management Steps:

1. Remove the partially hanging nail completely to expose the nail bed for direct visualization 1

2. Thoroughly inspect the nail bed for lacerations that require repair 1

   • Crush injuries with distal phalanx fractures typically involve nail bed lacerations 1
   • The extent of injury is consistently underestimated without nail removal 1

3. Repair the nail bed if lacerations are present 1

   • Formal nail bed reconstruction is indicated for significant lacerations 1
   • Adequate initial assessment and treatment are essential for functional and cosmetic outcomes 1

4. Address the fracture 3

   • Most distal phalanx fractures from crush injuries require care for surrounding soft tissues but rarely need specific fracture treatment 3
   • The fracture itself typically heals with conservative management 3

5. Splint the distal interphalangeal joint for 4-6 weeks 4

Critical Pitfalls to Avoid

Do not assume the nail bed is intact based on external appearance alone. 1 Physicians at the emergency department frequently underestimate these injuries, with 40% being missed by initial treating providers in one series. 2

Do not delay treatment. Missed or delayed diagnosis of these injuries results in infection, pain, nail deformity, and physeal arrest. 2 The mean time from injury to surgical treatment should be minimized (ideally within 2-3 days). 2

Alternative Approach (Not Recommended in This Context)

Simple nail trephination without nail removal has been studied for isolated subungual hematomas without fracture, showing comparable outcomes to formal nail bed repair. 5 However, this approach is not applicable when there is a distal phalanx fracture and partially hanging nail, as these injuries require direct visualization of the nail bed to assess for lacerations. 1