Referral for Total Fingernail Avulsion in a 6-Year-Old
A 6-year-old child with a total fingernail avulsion should be referred to a pediatric plastic surgeon for definitive management. 1
Primary Recommendation
- Pediatric plastic surgeons are the guideline-recommended specialists for hand trauma in children, specifically including bone, tendon, and skin injuries. 1
- The American Academy of Pediatrics explicitly states that "infants, children, and adolescents with trauma to the hand, specifically including bone, tendon, and skin injuries, should be referred to a pediatric plastic surgeon." 1
- At 6 years of age, this child falls within the defined "child" category (2-12 years) where pediatric surgical specialists are strongly preferred. 1
Alternative Specialist Options
If a pediatric plastic surgeon is not readily available, consider these alternatives in order of preference:
- Pediatric surgeon: Children 5 years or younger who may need surgical care should be cared for by a pediatric surgeon, and this 6-year-old is close to this threshold. 1
- General plastic surgeon or pediatric surgical specialist with appropriate education, training, and experience in pediatric hand injuries may be acceptable alternatives. 1
Clinical Rationale
- Nailbed injuries in children require meticulous repair under magnification to prevent long-term complications including split nail deformity (5.3%), fingertip sensitivity issues (5.3%), infection (3.9%), nonadherence of the nail plate (2%), and hook nail deformity (1%). 2, 3
- Total avulsion injuries carry higher complication risks than simple lacerations, making specialist care particularly important. 2
- The fingernail plays a critical role in hand function, facilitating pinch and increasing fingertip sensitivity, making proper initial treatment essential to avoid aesthetic and functional impairment. 3
Important Caveats
- Do not attempt replantation of an avulsed primary tooth if this injury involves the mouth, but a fingernail avulsion requires specialist surgical repair. 1
- Initial stabilization can occur at a local facility, but transfer to a center with pediatric plastic surgery expertise should follow promptly. 1
- Pediatric emergency physicians manage many nailbed injuries (72.2% in one series), but total avulsion represents a more complex injury requiring specialist consultation. 2
- Associated distal phalanx fractures increase complication risk and further support specialist referral. 2