What is the appropriate method to remove a sub‑nail foreign body in an otherwise healthy 8‑year‑old child?

Removing a Subungual Splinter in an 8-Year-Old Child

For a splinter under the fingernail in an 8-year-old, remove the overlying nail plate with fine scissors or a nail clipper to expose the splinter, then extract it with fine forceps or a needle under direct visualization.

Initial Assessment

Before attempting removal, examine the finger for:

• Signs of infection (erythema, warmth, purulent drainage, or increased pain beyond the initial injury) 1
• Depth and location of the splinter relative to the nail plate 2
• Composition of the foreign body if known (wood splinters are particularly prone to causing infection) 2

Removal Technique

Step 1: Prepare the Area

• Clean the finger with antiseptic solution such as 2% povidone-iodine 3
• Consider topical anesthetic (EMLA cream or lidocaine gel) applied 20-30 minutes before the procedure for pain control in children 4

Step 2: Expose the Splinter

• Remove the overlying nail plate using fine scissors or a nail clipper to create adequate visualization of the foreign body 4
• The nail plate in children is thinner and grows faster than in adults, making this approach more feasible 2
• If the splinter is very distal (near the free edge), you may be able to trim back the nail edge without more extensive removal 4

Step 3: Extract the Foreign Body

• Use fine forceps or a sterile needle to grasp and remove the splinter under direct visualization 4
• Remove the entire foreign body to prevent granulomatous reaction and subsequent infection 2
• Ensure complete removal, as retained material triggers inflammation and infection 2

Post-Removal Care

Immediate Management

• Apply antiseptic to the nail bed after removal 3
• Protect the exposed nail bed with a sterile dressing 1
• Instruct parents to keep the area clean with gentle washing 1

Follow-Up Soaking Protocol

• Perform daily antiseptic soaks with dilute vinegar (50:50 dilution with water) or 2% povidone-iodine for 10-15 minutes twice daily for 3-5 days 3
• This prevents secondary infection and promotes healing 3

Antibiotic Considerations

• Do NOT routinely prescribe antibiotics for simple splinter removal without signs of infection 2
• If signs of infection develop (pus, increasing erythema, warmth), obtain cultures and initiate oral antibiotics targeting Staphylococcus aureus and gram-positive organisms 3, 1
• Wood splinters have higher infection risk and warrant closer monitoring 2

Critical Pitfalls to Avoid

• Never attempt blind removal without adequate visualization—this risks pushing the splinter deeper or causing additional nail bed trauma 4
• Do not underestimate trauma in children—if there is concern for deeper injury, nail bed laceration, or if you cannot achieve adequate removal, refer to a hand surgeon 5, 4
• Avoid excessive manipulation of the nail fold and cuticle during removal, as this increases infection risk 1
• Ensure tetanus prophylaxis is current for any penetrating injury 4

When to Refer

Refer to a specialist if:

• The splinter cannot be visualized or removed with simple nail plate trimming 4
• There is significant nail bed injury requiring repair 6
• Signs of infection are present at initial presentation, particularly with purulent drainage 1, 4
• The child is uncooperative and sedation may be required for adequate removal 6

Expected Healing

• The nail bed typically heals within 1-2 weeks after foreign body removal 1
• The nail plate will regrow over several months (faster in children than adults) 2
• Monitor for signs of infection including increased pain, redness, swelling, or drainage in the first week 1