What types of nail bed injuries are there?
Nail bed Laceration
Nail bed avulsion
What are the most common hand injuries seen in A/E?
Finger tip injuries
What is the pathophysiology of nail tip injuries?
Crush between 2 objects
Catch finger in closing door
Direct blow from hammer
What are the associated conditions?
Fracture or dislocation of the DIP
What is the prognosis of the condition?
Early operative treatment best outcome
Better outcome with fracture fixation and repair of nail bed at same time
Can you draw and name the sections through a nail?
Hyponychium- skin immediately palmar to nail, at junction of sterile matrix and fingertip skin
Eponychium- the dorsal nail fold, proximal to nail plate
Lunula- white portion of proximal nail
Perionychium- entire area includes- nail/nailbed/surrounding skin
Paronychium- Lateral nail fold
Sterile matrix- soft tissue deep to and adherent to nail, distal to Lunula
Germinal Matrix- responsible for nail development
Perosteum of distal phalanx- immediately volar to sterile matrix
Extensor tendon insertion to Germinal matrix is 1.2-1.4 mm
What is the position of the sterile matrix?
Distal to Lunula
Aherent to nail
Soft tissue deep to nail
What is the position and role of the germinal matrix?
proximal to STERILE matrix
extensor tendon is 1.2-1.4 mm proximal to germinal matrix
responsible for nail development
What do you examine with a pt suspected of nail bed injury?
What investigations would you order?
nail bed integrity
Xray Ap, lateral and oblique to rule out fracture
What is this? and its treatment?
1) if less than 50% nail involved incise and drain using electrocautery/ needle
2) if greater than 50% nail bed removal , incision and drainage and nail bed repair
What is this and what is its treatment?
Nail bed laceration
Tx by nail removal , incision and drainage with nail bed repai using 6.0
NB: don't forget tetanus and prophylaxtic antibiotics
What is and its treatment?
Nail avulsion and portion of nail bed loss
Usually high energy injuries- commonly associated with fractures
tx 1) nail removal, nail bed repair +/- FX fixation = with minimal loss of matrix
2) nail removal, nail bed repair, split skin graft vs matirx nail transfer +/- FX fixation= avulsion of sig loss of matrix, nail matrix transfer from neighbouring injured finger or 2nd toe
Describe how would you repair a nail bed injury?
Soak nail in betadine
Repair nail bed with 6.0 or smaller absorable suture
RCT shown quicker repair time with Dermabond (2-octylcyanoacrylate) cf sutures- similar cosmesis and functional
support eponychial fold with original nail, foil, non adherent gauze
What are the complications of nail bed injuries?
Hook nail ( picture)
What is the complication and cause of the picture?
How is it treated?
Advancement of the matrix to obtain coverage without adequate bony support
tx= Remove nail and trim matirx to level of bone
What is the compliciation and cause of the picture?
How is it treated?
Scarring of matrix following injury to nail bed
TX: excise scar tissue and replace nail bed
What is this called and how do you treat it?
Seymour fracture- juxtaepiphyseal fracture of the distal phalanx
Treatment of a nail bed avulsion and physeal separation is irrigation and debridement, physeal reduction, nail bed repair and immobilization. The primary goals are to achieve a stable, viable nail and good cosmetic results.
Inglefield at al JBJS 95 retrospectively reviewed 19 children with 22 nail bed injuries. Early operative repair led to good to excellent results in 91% of patients. They concluded that repair of the nail bed at the time of injury is superior to secondary correction
Fassler JAm Ac O Surg 1996 -reviewed fingertip injuries, providing recommendations for treatment based on degree of soft tissue loss, bone exposure, feasibility for flap coverage and the presence or absence of mitigating systemic conditions. He also concluded that the outcome of nail bed injuries is dependent on the severity of injury to the germinal matrix.