A 20 year old female with no significant past medical or surgical history presents after a large piece of equipment smashed her finger as it fell to the floor while she was at work. She takes no medications and occasionally drinks socially.
Her nails is avulsed with a majority of the nail lifted from the nail bed. Her finger is neurovascularly intact. Capillary refills is less than two seconds. There is good sensation on lateral, medial, dorsal, and palmar aspects of the finger. (In children, who cannot tell you about sensation, you can soak their finger in warm water for 5 minutes. If the skin on the tip of the finger wrinkles, they are neurologically intact. If it stays smooth, there could be nerve damage.)
Vitals: T 36.8, HR 67, BP 129/89, SpO2 98%, RR 16
Imaging: Right fingers XR shows no acute fracture or dislocation.
Procedural Steps to Nail Avulsion with Nail Bed Injury
Perform a digital Block with 1% or 2% lido without epi
Apply finger tourniquet. Cutting the arm tourniquets in half lengthwise works well. Or one can cut the middle finger off a glove and cutting a hole in the tip. Roll it down the finger to make a tourniquet.
Remove the nail using fine tip scissors or a curved hemostat. Enter parallel to the nail bed with tip angled toward the nail to avoid hurting the nail bed. Open and Spread. Do this along several tracts, until the nail is no longer adherent to the nail bed. Once the nail is no longer adherent, grasp with hemostat and pull from base to ensure that nail is completely removed. If you can reuse the nail, store it in a container with a mixture of providone and normal saline.
Irrigate the nail bed with 100-200 ml of normal saline
Repair nail bed with 6-0 or 7-0 Chromic gut sutures. The nail bed is very fragile, so be gentle and insert suture needle distal to proximal, and use as few sutures as possible. Make sure the lac is aligned as precisely as possible. There have been several small studies that have shown that dermabond works just as well as sutures. In order to use it, you need to have a clean, bloodless field.
Stent open the nail fold with the original nail if possible.
Make a hole in the nail to allow for drainage
As precisely and anatomically correct as you can be, place the nail in the nail fold and either glue it, or place 2 4-0 chromic sutures through the nail into the lateral skin folds.
If you can't use the original nail, cut the foil from the chromic suture package to look like a nail then glue or suture it in.
Dress it with one layer of vaseline gauze or xeroform, then gauze. Complete the wrap with a finger splint. The patient should not take off the dressing until they visit a hand clinic within the week.
Another patient comes in to the ED with the exact same mechanism of injury as the above, except her nail is intact. However, she has a subungal hematoma. What should you do?
The recommendation used to be that if the subungal hematoma was > 25-50% of the nail, then you needed to remove the nail and check for nail bed lacs. Now they do not recommend removing the nail if all else looks ok. You can just trephinate (burr a hole in the nail) instead.
It is best to use the electrocautery (bovie) knife. You do not have to put any pressure on the nail. Be careful to not use anything that could be flammable around it (i.e. alcohol. Best to clean the nail with chlorohexidine).
Other options are to use an 18 gauge needle. Put it over the hematoma and twirl with gentle pressure. Stop as soon as you break through the nail.
If the hematoma is under a small nail, or distal, you can put a 30 gauge needle on a syringe, put the needle under the nail, parallel to the nail bed and suck out the blood.
Lyndsay Massey, MD is a current second year resident at Stony Brook Emergency Medicine.
Edited by Bassam Zahid, MD