How to document an avulsed toenail?

Medical Documentation of Toenail Avulsion

Document a toenail that has fallen off as "traumatic nail avulsion" or "spontaneous nail avulsion" depending on the mechanism, with detailed description of the nail bed condition, surrounding tissue status, and any underlying pathology that may have contributed to the loss.

Essential Documentation Components

Primary Description

• Use the term "nail avulsion" to describe the complete separation of the nail plate from the nail bed 1
• Specify whether the avulsion was:
  • Traumatic (acute injury-related)
  • Spontaneous (secondary to underlying disease process such as onychomycosis, chronic paronychia, or nail dystrophy) 1, 2
  • Complete (entire nail plate) versus partial (portion of nail plate)

Detailed Wound Assessment

• Measure and record the exposed nail bed dimensions (length × width in millimeters or centimeters) 3
• Document the quality of the nail bed tissue:
  • Intact versus damaged
  • Color (pink, pale, erythematous, or discolored)
  • Presence of granulation tissue
  • Any visible matrix exposure 3
• Assess surrounding structures:
  • Lateral nail folds: presence of erythema, edema, or tenderness 2
  • Proximal nail fold: signs of paronychia or inflammation 3
  • Periungual skin: maceration, cellulitis, or other abnormalities 3

Associated Findings

• Document any drainage: color, quantity, consistency, and odor 3
• Note presence of:
  • Exposed bone (use sterile probe to assess if bone is palpable—has characteristic "stony feel") 3
  • Foreign bodies 3
  • Callus or hyperkeratosis around the wound 3
  • Signs of infection (purulent discharge, warmth, spreading erythema) 3

Underlying Pathology Assessment

• Identify contributing factors:
  • Onychomycosis: Document if nail plate showed prior dystrophy, discoloration, subungual debris, or friability 3
  • Chronic trauma: Repetitive injury patterns, occupational or footwear-related 3
  • Ingrown toenail: Previous lateral nail fold inflammation or granulation tissue 2
  • Psoriasis, lichen planus, or other dermatologic conditions 3
  • Peripheral neuropathy or diabetes: Critical to document as these patients may have occult fractures or Charcot changes despite minimal symptoms 3, 4

Clinical Context Documentation

Mechanism and Timing

• Document how the nail was lost:
  • Acute trauma with specific mechanism (crush injury, stubbing, sports injury)
  • Gradual loosening over days to weeks
  • Found already detached without clear precipitating event 1
• Timeline: When patient first noticed loosening versus complete separation

Functional Impact

• Pain level (0-10 scale) at rest and with ambulation
• Ability to bear weight and walk normally 4
• Impact on activities of daily living

Special Considerations and Pitfalls

High-Risk Patients Requiring Enhanced Documentation

• Diabetic patients or those with peripheral neuropathy: These patients may have fractures or bone involvement despite minimal pain and ability to walk—document neurovascular status and consider imaging even with seemingly minor trauma 3, 4
• Immunocompromised patients: Higher infection risk requiring closer monitoring 3

When to Obtain Imaging

• Radiographs are indicated if:
  • Significant trauma mechanism suggests possible fracture 3
  • Bone is palpable with probe 3
  • Patient has diabetes/neuropathy (may have occult fracture despite minimal symptoms) 4
  • Suspicion of foreign body (if radiopaque) 3

Specimen Collection (If Indicated)

• If infection is suspected and nail plate is available:
  • Collect nail plate specimen for fungal culture and microscopy 3
  • Obtain tissue from nail bed (not superficial swab) for bacterial culture if infection present 3
  • Document specimen collection method and site 3

Differential Documentation

• Distinguish from conditions that mimic traumatic avulsion:
  • Onycholysis (nail separation but plate still attached distally) 3
  • Onychogryphosis (thickened, dystrophic nail) 3
  • Note that repetitive trauma can cause distal onycholysis leading to secondary colonization and eventual complete avulsion 3

Follow-Up Documentation Points

• Healing progress: Measure wound size at each visit to track improvement 3
• Nail regrowth: Document when new nail plate becomes visible (typically begins 2-4 weeks post-avulsion)
• Complications: Infection, abnormal regrowth, persistent pain 1, 2