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Introduction
Introduction
- Injury to the nail bed (soft tissue underlying the nail plate) in the forms of (1) :
- Subungal haematoma
- Nail bed laceration
- Nail bed avulsion
- Mechanism of injury:
- Crush injury to the fingertip between two objects/closing door
- DIY (saw or hammer blow)
- Commonly associated with distal phalanx fractures
Assessment (2)
Assessment (2)
- XR finger
- AP, lateral, oblique
- If fracture present treat as an open fracture
Management
Management
- Immediate Management (3,4):
- Remove all jewellery
- Check tetanus status
- Give analgesia
- PO antibiotics (consult local guidelines)
- Washout (use LA if not tolerated)
- Dressing (non-adherent e.g. atrauman)
- Splint if needed
- Elevate in Bradford sling
- Open fracture of distal phalanx
- Manage as above
- Most nail bed and fingertip injuries are open fractures. They do not require special management unless DIPJ involved or present in a child
- Children
- Children are commonly admitted to the paediatric ward for theatre the following morning as first on the CEPOD list
- It is also possible to discharge with instructions to come the following day at 0730. Make sure to inform the ward and ensure they receive ED documentation
- Ensure proper NBM instructions are given!
- Special cases
- Seymour Fracture - Nail bed injury with underlying distal phalanx fracture through physis. This is commonly an open fracture with the soft tissue of the nail bed interposed between the fracture fragments. If untreated it can lead to osteomyelitis!
- Tip amputation - DO NOT DISPOSE OF ANY AMPUTATED PARTS WITHOUT SENIOR DISCUSSION. Generally this injury does not allow for replantation as the distal vessels are too fine for anastamosis. However, in children the tip can be replanted as a composite graft and act as a biological dressing that aids healing.
- Nonperfused tip - Attempt to correct any rotation that may be kinking vessels, but otherwise you cannot salvage small distal flaps. Manage as above and discuss with senior. Do not debride tissue as it may be bruised but viable!
- Subungal haematoma - If involving over 50% of the nail bed and painful consider trephining the nail, or removing it. This will likely confirm a nail bed laceration which can be managed as above
References
References
1. Chiu TW. Stone’s Plastic Surgery Facts: A Revision Guide, Fourth Edition. CRC Press; 2018. 2. Green DP, Wolfe SW. Green’s operative hand surgery. Elsevier/Churchill Livingstone; 2011. 3. George A, Alexander R, Manju C. Management of Nail Bed Injuries Associated with Fingertip Injuries. Indian J Orthop. 2017;51(6):709–13. 4. The British Society of Surgery for the Hand. Hand Injury Triage App [Internet]. [cited 2020 Feb 2]. Available from: handinjurytriageapp.bssh.ac.uk
Image References:Header Image: Licensed with Adobe Stock 2019"Nail Bed Injury" Image Reference: Orthobullets "Nail Bed Injuries" Article, section on Nail Avulsion injuries. Accessed in Dec 2019
Image References:Header Image: Licensed with Adobe Stock 2019"Nail Bed Injury" Image Reference: Orthobullets "Nail Bed Injuries" Article, section on Nail Avulsion injuries. Accessed in Dec 2019
This subpage has been reviewed by:
1) Mr. Martin Shapev - Plastic Surgery Registrar, RD&E (09/02/2020)
1) Mr. Martin Shapev - Plastic Surgery Registrar, RD&E (09/02/2020)
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