What is the procedure for nail bed repair of simple lacerations?

Updated: Aug 25, 2020
  • Author: Rahi K Yallapragada, MBBS, MRCS, FRCS(T&O), MCh(Orth); Chief Editor: Erik D Schraga, MD  more...
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Answer

Answer

When a subungual hematoma exists with an intact nail, an underlying simple laceration may be present. If the laceration does not extend beyond the lateral nail fold and if no significant deformity or fracture of the nail is present, the nail should not generally be removed to rule out laceration. In this situation, the laceration is more likely to heal well without nail removal and laceration repair. Instead, nail trephination alone can be performed to evacuate the subungual hematoma. See the image below.

Trephination of a subungual hematoma. Trephination of a subungual hematoma.

Explore the nail bed under loupe magnification (if necessary).

Trim the irregularities so that the tissue can be repaired without any tension on closing.

For accurate wound approximation, undermine one millimeter of the nail bed from the periosteum (this allows slight eversion of the wound edges).

After the nail bed is accurately approximated, suture the margins of the laceration with 6-0 or 7-0 absorbable monofilament sutures.

Drill a round hole or burn through the nail plate at a point not over the repair site to allow drainage of serum or hematoma from the subungual area after the nail is reinserted into the nail fold (the nail keeps the fold open and better molds the edges of the repair).

Hold the nail in place with Steri-Strips or a 6-0 monofilament nylon suture placed either through the fingertip and the distal free border of the nail plate or through the lateral nail folds and nail plate. Another option is a dorsal figure-of-eight suture. To achieve this stitch, place a suture transversely just distal to the hyponychium, then take another bite proximal to the nail fold in the same direction and tie it back to the initial stitch location.

Apply nonadherent dressings and a splint that immobilizes the distal interphalangeal joint and protects the tip.

The dressing needs to be changed in 5-7 days and the nail checked for subungual seroma or hematoma.

The suture should be removed from the tip at 2-3 weeks.

The nail frequently adheres to the nail bed for 1-3 months until pushed off by the new nail.

Replacement of the nail creates a much less tender fingertip while a new nail is growing. However, not placing the nail plate back into the nail fold is also an option.


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