What is the initial treatment for a nail bed injury?

Initial Treatment for Nail Bed Injury

The standard initial treatment for nail bed injury requires nail removal when indicated (severe pain, pressure hematoma, or subungual abscess), followed by meticulous cleaning, repair of the nail bed laceration, and infection prevention measures. 1, 2

Immediate Assessment and Pain Control

• Administer local anesthesia for pain control before any procedure 2
• Evaluate for nail removal indications: severe pain, pressure hematoma under the nail, or subungual abscess formation 1
• Assess for associated distal phalanx fractures, which are common with nail bed injuries and predict higher complication rates 3

Nail Removal and Repair Protocol

When nail removal is indicated, carefully remove the nail to expose the underlying nail bed laceration for proper visualization and repair. 1

• Remove the nail to allow meticulous cleaning and repair of the nail bed 1, 2
• Thoroughly clean the nail bed during the procedure 1
• Perform meticulous repair of any nail bed lacerations after cleaning 2
• Failing to remove the nail when indicated leads to chronic onycholysis and persistent subungual hyperkeratosis 1

Infection Prevention and Management

If pus is present, obtain bacterial cultures immediately and initiate antibiotics with anti-staphylococcus aureus and gram-positive coverage. 1, 2

• Obtain bacterial cultures if infection is suspected 1
• Start appropriate antibiotics targeting Staphylococcus aureus and gram-positive organisms when infection is present 2
• Apply daily dilute vinegar soaks (50:50 dilution) to nail folds twice daily to reduce inflammation 2
• Use mid to high potency topical steroid ointment to nail folds twice daily for edema and pain 1, 2

Post-Repair Care

• Keep the affected area clean and dry between treatments to prevent infection and promote healing 4
• Use pH5 neutral bath formulations with tepid water for cleaning, avoiding harsh soaps 4
• Apply topical petrolatum around the nails for lubricant and smoothing effects 4
• Apply hypoallergenic moisturizing creams or ointments once daily to prevent dryness 4

Ongoing Management

• Perform regular nail trimming until the nail plate grows reattached 1, 2
• Cut nails straight across until they no longer extend over the toes 4
• Monitor for signs of infection including increased pain, redness, swelling, or purulent drainage 2
• Avoid friction and pressure on the nail fold and avoid picking or manipulating the nail bed 4

Management of Granulation Tissue

If granulation tissue develops:

• Consider scoop shave removal with hyfrecation 2
• Alternatively, apply silver nitrate 2

Critical Pitfalls to Avoid

• Inadequate initial assessment and treatment lead to substantial clinical problems and unpredictable results with secondary reconstruction 5, 6
• Failing to remove the nail when indicated causes chronic complications 1
• Inadequate cleaning and debridement of the nail bed leads to poor outcomes 1
• Delayed treatment increases the risk of secondary deformities 5

Predictors of Complications

• Stellate lacerations and severe crushed nail bed injuries predict higher complication rates 3
• Associated distal phalanx fractures increase risk of complications and need for antibiotics 3
• Crush or avulsion injuries have poorer outcomes compared to simple lacerations 7
• Injuries involving both nail bed and nail fold result in worse outcomes 7