What is the recommended treatment for a 51-year-old male with a history of traumatic injury to the right ring finger, resulting in the loss of the fingertip, who is now experiencing problematic fingernail growth requiring constant maintenance?

Nail Ablation with Phenol Matricectomy for Chronic Dystrophic Nail Following Traumatic Fingertip Amputation

For this 51-year-old male with a chronically problematic dystrophic nail following traumatic fingertip amputation, permanent nail ablation using phenol matricectomy is the appropriate definitive treatment to eliminate the ongoing maintenance burden and prevent nail regrowth.

Clinical Context and Rationale

This patient presents with a classic scenario where the initial traumatic injury has resulted in a dysplastic, hooked nail that requires constant maintenance without serving any functional purpose. The examination confirms full range of motion, intact sensation, and no infection—indicating that the underlying fingertip has healed adequately but the nail apparatus remains problematic 1, 2.

Why Permanent Nail Ablation is Indicated

• The dystrophic nail serves no protective function and creates ongoing burden for the patient, who specifically requests removal 3, 4
• Phenol matricectomy provides permanent ablation by chemically destroying the germinal matrix, preventing regrowth in the majority of cases 5
• The procedure is well-tolerated under digital block anesthesia and can be performed in an office setting with minimal morbidity 4

Procedural Approach

Technique Details

• Anesthesia: Single digital block injection in the palm provides adequate anesthesia 4
• Tourniquet application: Essential for hemostasis and clear visualization during matrix destruction 5
• Nail plate removal: Complete avulsion using a scraping tool to expose the entire nail bed and matrix 6
• Chemical matricectomy: Application of phenol (typically 88-90% concentration) to the exposed germinal matrix for 2-3 minutes to achieve permanent ablation 5
• Neutralization: Thorough irrigation with alcohol or saline to prevent tissue damage from residual phenol 5

Expected Outcomes and Healing

• Healing time: Approximately 2 weeks for complete epithelialization of the nail bed 4
• Wound care: Simple routine hand washing with soap and water is sufficient; no complex dressing changes required 3, 4
• Success rate: Phenol matricectomy achieves permanent nail ablation in 85-95% of cases 5
• Recurrence risk: Small possibility (5-15%) of partial or complete nail regrowth requiring repeat treatment 5

Important Considerations and Pitfalls

Common Complications to Counsel About

• Incomplete ablation: If any germinal matrix cells survive, partial nail regrowth may occur, appearing as a small nail spike that can be more problematic than the original nail 5
• Prolonged drainage: The phenol-treated area may drain serous fluid for 2-4 weeks, which is normal and not indicative of infection 4
• Hypergranulation tissue: May develop during healing but typically resolves spontaneously or responds to silver nitrate application 6, 5

Key Technical Points

• Complete matrix exposure is critical: Failure to remove all nail plate material before phenol application will result in incomplete matricectomy 6
• Adequate phenol contact time: Insufficient application time (less than 2 minutes) increases recurrence risk 5
• Avoid phenol spillage: Protect surrounding skin with petroleum jelly to prevent chemical burns 5

Alternative Approaches Not Recommended in This Case

Why Conservative Management is Inappropriate

• Topical treatments have no role for mechanical nail dystrophy following trauma—this is not onychomycosis or inflammatory disease 6
• Repeated nail trimming perpetuates the problem without addressing the underlying dysplastic matrix 7
• Secondary intention healing is not applicable since the fingertip has already healed; the issue is the abnormal nail apparatus 3

Why Surgical Excision Alone is Inferior

• Simple nail avulsion without matricectomy results in regrowth of the same dystrophic nail within 3-6 months 6
• Surgical matricectomy (without phenol) has higher recurrence rates and more postoperative pain compared to chemical ablation 5

Post-Procedure Monitoring

• Follow-up at 2 weeks: Assess healing and ensure no signs of infection 4
• Follow-up at 3-6 months: Evaluate for any nail regrowth that would indicate incomplete matricectomy 5
• Patient education: Emphasize that any small nail spicule growth should be reported early, as repeat phenol application is more effective when performed before significant regrowth occurs 5