What are the guidelines for nail removal from the wrist?

Nail Removal from Wrist Following Penetrating Injury

For nail gun injuries to the wrist, perform simple emergency room removal with local debridement and a short course of oral antibiotics covering Staphylococcus aureus—this approach is appropriate for most cases without intra-articular or neurovascular involvement. 1

Immediate Assessment and Decision-Making

Determine if operative debridement is required by evaluating for:

• Intra-articular involvement (joint penetration) 1
• Neurovascular injury 1
• Presence of pus or abscess formation 2

If any of these are present, proceed to operative debridement rather than simple removal. 1

Removal Technique

Use a claw hammer for nail extraction rather than typical operating room equipment, as this prevents nail head deformity and breakage that complicates the procedure. 3 The hammer should be:

• Obtained from materials management 3
• Autoclaved for sterility 3
• Used with a block or surgical pan lid to gain leverage and protect soft tissues 3

Administer local anesthesia before the procedure for pain control. 2 Ropivacaine 1% is recommended for anesthesia in nail procedures. 4

Wound Management After Removal

Perform meticulous cleaning and debridement of the wound after nail extraction to prevent chronic complications. 2 Inadequate cleaning leads to persistent problems and infection risk. 2

If pus is present:

• Obtain bacterial cultures before starting antibiotics 2, 5
• Target Staphylococcus aureus and gram-positive organisms 2, 5

Antibiotic Therapy

Initiate oral antibiotics immediately if infection is suspected (increased pain, redness, swelling, purulent drainage, or warmth). 5

Recommended oral antibiotic options include:

• First-generation cephalosporins 5
• Amoxicillin-clavulanate 5
• Clindamycin 5
• Doxycycline 5

Note: Prophylactic antibiotics are not routinely indicated for clean puncture wounds without signs of infection. 5 However, the evidence from nail gun injuries suggests a short course is appropriate in most cases. 1

Adjunctive Care

Apply daily dilute vinegar soaks (50:50 dilution) to the wound site twice daily to reduce inflammation. 2, 5

Consider mid to high potency topical steroid ointment applied twice daily for edema and pain control. 2, 5

Follow-Up and Monitoring

Reassess after 2 weeks to determine if infection has worsened or failed to improve with oral antibiotics and local care. 5

Watch for signs requiring escalation:

• Increased pain, redness, or swelling 2
• Purulent drainage 2
• Development of abscess 5

Critical Pitfalls to Avoid

Do not attempt simple removal if there is intra-articular or neurovascular involvement—these cases require operative debridement. 1 The study of 88 nail gun injuries found infections were rare (3.4%) and limited to patients presenting later than the day of injury, supporting the effectiveness of prompt treatment. 1

Avoid using typical operating room equipment for nail extraction, as this commonly results in nail head deformity and breakage, making completion of the procedure more difficult. 3