What is the appropriate treatment for a great toe laceration through the nail?

Treatment of Great Toe Laceration Through the Nail

The standard treatment for a great toe laceration through the nail requires nail removal, meticulous cleaning and repair of the nail bed, followed by infection prevention measures and appropriate wound care. 1

Initial Assessment and Management

Remove the nail plate to access and properly repair the underlying nail bed laceration. 1 This is essential because:

• The nail must be removed to allow thorough cleaning of the wound and prevent infection 1
• Failure to remove the nail when indicated can lead to chronic onycholysis and persistent subungual hyperkeratosis 1
• Nail bed lacerations cannot be adequately repaired without nail removal 1

Administer local anesthesia for pain control prior to the procedure. 1 Buffered lidocaine provides effective anesthesia with minimal discomfort 1

Obtain bacterial cultures if there are any signs of infection (purulent drainage, erythema, warmth, or swelling). 1

Repair Technique

After nail removal, meticulously clean and repair the nail bed laceration. 1 The key steps include:

• Thoroughly irrigate and clean the nail bed to remove debris and prevent infection 1
• Carefully approximate the nail bed edges with fine sutures 1
• Ensure precise alignment to prevent future nail deformities 1

Infection Prevention and Post-Repair Care

If pus is present, initiate antibiotics with coverage against Staphylococcus aureus and other gram-positive organisms. 1

Prescribe daily dilute vinegar soaks (50:50 dilution with water) to the nail folds twice daily to reduce inflammation and prevent infection. 1

Apply mid to high potency topical steroid ointment to nail folds twice daily if there is significant edema and pain. 1

Instruct the patient on regular nail trimming as the nail plate grows back and reattaches. 1

Monitoring for Complications

Watch for signs of infection including:

• Increased pain, redness, or swelling 1
• Purulent drainage 1
• Fever or systemic symptoms 1

If infection develops despite initial treatment, obtain cultures and adjust antibiotic therapy accordingly. 1

Important Caveats

• This injury pattern (laceration through the nail) in the great toe may indicate an underlying open fracture of the distal phalanx, particularly if there is bleeding at the nail base or a laceration proximal to the nail fold 2
• Consider radiographs to rule out fracture, especially in pediatric patients where growth plate injuries can occur 2
• Unrecognized open fractures can lead to osteomyelitis or growth disturbances if not properly treated 2