Nail Replacement and Anchoring After Avulsion
After removing a damaged nail, the standard approach is to replace the original nail plate (if available and clean) or use a substitute material to protect the nail bed, anchor it in place under the proximal nail fold, and maintain the nail fold space until the new nail grows out. 1
Purpose of Nail Replacement
The replaced nail serves three critical functions:
- Protects the tender nail bed from painful stimuli during the healing process 2
- Prevents adhesions between the proximal nail bed and nail fold that would impair new nail growth 2
- Maintains the nail fold space to allow proper regrowth of the new nail plate 1
Technique for Anchoring the Replaced Nail
Using the Original Nail Plate
- Clean and disinfect the avulsed nail thoroughly if it is intact enough to use 2
- Trim the nail to match the profile of the nail bed if damaged portions exist 2
- Thin the proximal edge to reduce thickness and ease insertion under the proximal nail fold 2
- Create a small central hole to allow blood and fluid drainage 2
- Insert the proximal edge under the nail fold and secure it in place 1
Securing Methods
- Sutures can anchor the nail plate through small perforations to the surrounding tissue 3
- Formable acrylic may be used for fixation in complex cases 1, 4
- The nail typically remains in place for approximately one month until sufficient new nail growth occurs 2
Alternative Materials When Original Nail Unavailable
Recent evidence challenges the dogma of always replacing the nail:
- A 2017 randomized trial found that replacing the nail plate increased infection rates and complications compared to discarding it after nail bed repair 5
- Bacterial cellulose dressing (Bio-Nail) showed superior outcomes with lower pain intensity, earlier reepithelization, and better nail bed preservation at 180 days 6
- Sterile polypropylene sheet can be trimmed to nail shape, is flexible, inexpensive, and provides good protection during healing 2
Post-Procedure Management
- Regular nail trimming is necessary until the new nail plate grows fully reattached 1
- Monitor for infection including increased pain, redness, swelling, or purulent drainage 1
- Daily antiseptic soaks with dilute vinegar (50:50) or 2% povidone-iodine twice daily reduce inflammation 1
- Mid to high-potency topical steroid ointment applied to nail folds twice daily manages edema 1
Critical Pitfall to Avoid
Delaying nail removal when indicated (severe pain, hematoma, or abscess present) can lead to permanent nail bed damage and chronic onycholysis 1. Once removed, promoting early nail bed coverage prevents keratinization and persistent subungual hyperkeratosis 1.