What is the treatment for a nail that has fallen off after trauma?

Treatment for Traumatic Nail Avulsion

For a nail that has fallen off after trauma, perform meticulous cleaning of the nail bed, apply topical povidone-iodine 2%, and initiate daily antiseptic soaks with dilute vinegar (50:50 dilution) twice daily, while monitoring closely for signs of infection. 1

Immediate Management

Initial wound care:

• Clean the nail bed meticulously at the time of nail loss 1
• Apply topical povidone-iodine 2% to the exposed nail bed 1
• If pus is present, obtain bacterial, viral, and fungal cultures immediately and initiate oral antibiotics with coverage against Staphylococcus aureus and gram-positive organisms 1, 2

Pain control:

• Local anesthesia should be administered if any manipulation or repair is needed 1

Daily Wound Care Protocol

Antiseptic soaking regimen:

• Perform dilute vinegar soaks (50:50 dilution with water) twice daily for 10-15 minutes 1, 3
• Alternatively, use 2% povidone-iodine soaks if vinegar is not available 3

Topical therapy:

• After each soak, apply mid to high-potency topical steroid ointment to the nail folds twice daily to reduce inflammation 1, 3
• Continue topical povidone-iodine 2% application 1
• Apply topical antibiotics/corticosteroids as needed 1

Infection Prevention and Monitoring

Watch for infection signs:

• Monitor for increased pain, redness, swelling, or purulent drainage 1
• Up to 25% of nail injuries develop bacterial or fungal superinfections 2

Antibiotic therapy if infection develops:

• For mild cases without systemic signs: topical therapy alone is sufficient 2
• For moderate infection: initiate cephalexin or amoxicillin-clavulanate 2
• For severe infection: obtain cultures and use culture-directed therapy 2

Management of Complications

Granulation tissue formation:

• First-line: Apply high-potency topical steroids 3
• If persistent: Perform scoop shave removal with hyfrecation or silver nitrate application 1, 3

Preventing disappearing nail bed (DNB):

• Promote nail reattachment as early as possible to prevent nail bed keratinization 1
• The key concern with prolonged onycholysis is irreversible epithelialization of the nail bed, which can occur after long-standing separation 4
• Regular nail trimming is necessary until the nail plate grows reattached 1

Follow-Up Protocol

Reassessment schedule:

• Reassess after 2 weeks either by healthcare professional or patient self-report 1
• Monitor wound healing and check for signs of infection or complications 1
• Continue antiseptic soaks if inflammation persists 3

Long-term management:

• Cut nails regularly until the nail plate grows reattached to prevent permanent onycholysis 1
• Avoid repeated trauma by wearing comfortable, well-fitting shoes 3
• Daily application of topical emollients to cuticles and periungual tissues helps maintain skin barrier function 3

When to Escalate Care

Consider surgical intervention if:

• Persistent pain or drainage beyond 2-4 weeks occurs 3
• Severe infection develops requiring drainage 2
• Nail bed laceration requires meticulous repair 1

Advanced treatment options:

• For significant nail bed defects, thin split-thickness toenail bed grafts can restore normal nail appearance, though this is typically reserved for complex cases 5

Critical Pitfalls to Avoid

• Do not delay appropriate wound care, as chronic onycholysis can lead to permanent nail bed damage and DNB 1, 4
• Avoid topical steroids if purulent drainage is present 2
• Do not use clindamycin for empiric coverage due to inadequate streptococcal coverage 2
• Ensure proper nail trimming technique (straight across, not too short) to prevent ingrown nails during regrowth 3