Management of Fingertip Laceration with Nail Involvement
For a fingertip laceration involving the nail, immediate wound irrigation with tap water, removal of the nail plate if the nail bed is lacerated, meticulous repair of the nail bed with absorbable suture, and replacement of the nail plate as a biologic dressing provides optimal healing outcomes. 1, 2
Initial Wound Assessment and Preparation
Wound Irrigation:
- Irrigate thoroughly with potable tap water using higher pressure and volumes (100-1000 mL), which is as effective as sterile saline and reduces infection rates 1
- Body temperature water is more comfortable than cold saline 1
- Adding soap to water irrigation is more effective than saline alone 1
Anesthesia:
- Local anesthetic with epinephrine (1:100,000 concentration) is safe for digital use and provides hemostasis 3
- Consider topical anesthetics (lidocaine-epinephrine-tetracaine) for superficial wounds to avoid infiltration pain 4
Wound Preparation:
- Nonsterile gloves are acceptable and do not increase infection risk compared to sterile gloves 3
- Prepare the wound site with povidone-iodine or chlorhexidine gluconate 1
Nail Bed Repair Technique
When the nail bed is lacerated, the following steps are essential:
- Remove the nail plate completely to visualize and access the nail bed laceration 2
- Repair the nail bed meticulously with fine absorbable sutures (6-0 or 7-0) using interrupted or continuous technique 2
- Replace any free segments of nail bed by suturing them in place as a free graft 2
- Replace the nail plate after repair as a biologic dressing to maintain the nail fold space and protect the repair 2
- If the original nail is too damaged, consider using a substitute material to maintain the nail fold architecture 2
Skin Closure Options
For the fingertip skin laceration itself:
- Direct closure is appropriate for small amputations (2-3 mm) or clean lacerations without significant tissue loss 2
- Use interrupted subcuticular sutures with monofilament material for precise skin edge approximation 5
- Slight beveling of skin edges and undermining with even thickness improves cosmetic outcomes 5
- Tissue adhesives can be used for low-tension areas but are less suitable for fingertips with high mechanical stress 3, 4
For wounds with tissue loss:
- Superficial wounds may be allowed to heal by secondary intention, particularly in children 2
- In pediatric patients, even amputated segments can be sutured back as biologic dressings with excellent healing 2
Post-Repair Management
Wound Care:
- Apply occlusive or semiocclusive dressings as wounds heal faster in moist environments 3
- After cleaning, cover with a clean occlusive dressing or topical antibiotic to keep the wound moist 1
- Daily dilute vinegar soaks (50:50 dilution) can reduce inflammation if edema or pain develops 1, 6
Infection Prevention:
- Monitor for signs of infection: increased pain, redness, swelling, purulent drainage, or warmth 6
- Culture any purulent material before starting antibiotics 1, 6
- If infection develops, initiate oral antibiotics covering Staphylococcus aureus (first-generation cephalosporins, amoxicillin-clavulanate, or clindamycin) 6
Follow-up:
- Arrange early follow-up within two weeks to assess healing 1
- Suture removal timing depends on location; fingertip sutures typically remain 10-14 days 3
- Tetanus prophylaxis should be provided if indicated 3
Critical Pitfalls to Avoid
- Never close a nail bed laceration without removing the nail plate - inadequate visualization leads to poor repair and nail deformity 2
- Do not use epinephrine concentrations higher than 1:100,000 on digits despite older teaching against any epinephrine use 3
- Avoid closing wounds under tension - this increases scarring and dehiscence risk 5
- Do not assume a "golden period" cutoff - depending on wound type, closure may be reasonable even 18+ hours after injury 3
- In diabetic patients, assess vascular status and infection risk before any nail procedures, as they have higher complication rates 7