Salvaging a Totally Avulsed Nail Bed Using Free Grafting and Postoperative Ice Cooling

A Case Report

Kun-Yong Sung, MD; Sang-Yeul Lee, MD


Wounds. 2021;33(4):E28-E30. 

In This Article

Case Report

A 26-year-old male injured the left fourth digit while using machinery. The patient presented to the emergency room with the amputated portion, which included the complete nail bed attached to a small area of the dorsal skin and an exposed distal phalanx with the periosteum denuded (Figure 1A). The amputated portion with the nail removed was divided into 2 parts—the nail bed and skin. Each was replanted in its original place as a free graft, and the patient was provided a digital nerve block (Figure 1B). The nail that had been separated from the amputated portion was kept in place for postoperative support. The surgical wound was lightly dressed using Mepilex Lite (Mölnlycke Health Care AB) and wrapped with a finger cot. The patient was discharged and instructed to keep the grafted nail bed cool by using vinyl bags filled with crushed ice continuously for 7 days, while taking care not to keep it too cold in order to avoid frostbite.

Figure 1.

(A) Totally avulsed nail bed with a small amount of dorsal skin from the left fourth digit. Denuded phalangeal bone was exposed with loss of the periosteum. (B) Immediate postoperative photograph showing nail bed and skin graft.

The patient returned to the outpatient clinic the next day for the surgical wound to be checked; thereafter, the patient was evaluated every other day for 2 weeks. Both the grafted nail bed and skin survived successfully, with no noteworthy events such as graft loss or infection, during a 4-week follow-up period (Figure 2A). The patient was instructed to frequently apply a moisturizing cream on the grafted area so that it did not dry out; this was continued beyond initial follow-up.

Figure 2.

(A) Four-week postoperative photograph showing successful take of grafts and (B) nail bed at 2-year postoperatively showing natural nail growth.

A 2-year postoperative examination showed natural nail growth and excellent fingertip appearance (Figure 2B). The patient did not experience any adverse events.