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Nail Bed Repair

 Nail Bed Repair

Nail Bed Repair will be dictated by the extent of the injury, the type of laceration present and the presence of associated pathology.

Small subungual hematomas (those involving <25% of the nail bed) can be managed with observation or trephination, if the area is painful.

For subungual hematomas involving more than 25% of the nail bed, nail plate removal is recommended for examination of the nail bed and repair of any laceration that may be present.

Treatment options for both simple and stellate nail bed lacerations include suture repair or the use of 2-octylcyanoacrylate (Dermabond).

See Also: Hand Anatomy
Nail Bed injury
Nail Bed injury

Necessary Supplies for Nail Bed Repair

Materials required for nail bed repair are described as follows:

  1. 1% lidocaine without epinephrine for digital nerve block .
  2. 10 cc syringe .
  3. 25- or 27-gauge needle for the digital nerve block .
  4. 0.5” or 1” penrose drain to act as a finger tourniquet .
  5. Povidone-iodine solution .
  6. Kidney basin.
  7. Sterile drapes.
  8. Laceration tray—necessary instruments include iris scissors, small needle driver, forceps and a small tissue elevator.
  9. 6-0 absorbable monofilament suture .
  10. 6-0 nylon suture (keep the foil package to use as an interposition underneath the eponychial fold if the patient’s nail is unavailable or unusable) .
  11. 2-octylcyanoacrylate (Dermabond, if this treatment approach is utilized) .
  12. Xeroform non-adherent dressing .
  13. Sterile dressings (gauze and kling wrap) .
  14. Finger splint.
  15. Loupe magnification (optional).
Nail Bed anatomy
Normal anatomy of the distal fingertip

Nail Bed Repair Technique

Suture Repair and 2-Octylcyanoacrylate Repair:

With the patient in supine position, the affected hand is placed palm down onto an arm extension or small mayo stand type table. The injured finger is copiously irrigated with saline removing any debris or contamination from the region of the nail. The finger is then prepped using povidone-iodine solution and the area is draped using a sterile extremity drape.

A digital nerve block is then provided making sure to cover all four digital nerves that supply the injured finger. The penrose drain is then applied as a finger tourniquet, wrapped from distal to proximal and anchored around the base of the finger. The nail plate is then removed and the nature of the nail bed laceration is assessed.

See Also: Nerve Block For Hand Surgery

Nail Plate Removal

Nail Plate Removal
Nail plate removal using the iris scissors placed between the nail bed and the nail plate

Suture Repair

Nail bed irrigation
Irrigating the nail bed for removal of hematoma or debris before Nail Bed Repair

2-Octylcyanoacrylate Repair

Nail Bed injury repair
Nail Bed Repair – Repairing the laceration using 6-0 absorbable monofilament sutures

Eponychial Interposition

Dressings and Follow-up Care

Nail Bed injury dressing
The repaired nail bed is covered in xeroform dressing, the finger is wrapped in gauze and a splint is applied

References

  1. Brown RE. Acute nail bed injuries. Hand Clin. 2002 Nov;18(4):561-75. doi: 10.1016/s0749-0712(02)00075-6. PMID: 12516973.
  2. Elbeshbeshy BR, Rettig ME. Nail bed repair and reconstruction. Tech Hand Up Extrem Surg. 2002 Jun;6(2):50-5. doi: 10.1097/00130911-200206000-00002. PMID: 16520617.
  3. Hart RG, Kleinert HE. Fingertip and nail bed injuries. Emerg Med Clin North Am. 1993 Aug;11(3):755-65. PMID: 8359141.
  4. Strauss EJ, Weil WM, Jordan C, Paksima N. A prospective, randomized, controlled trial of 2-octylcyanoacrylate versus suture repair for nail bed injuries. J Hand Surg Am. 2008;33(2):250-3.
  5. Van Beek AL, Kassan MA, Adson MH, Dale V. Management of acute fingernail injuries. Hand Clin. 1990;6(1):23-35; discussion 37-8.
  6. Zook EG, Guy RJ, Russell RC. A study of nail bed injuries: causes, treatment, and prognosis. J Hand Surg Am. 1984;9(2):247-52.

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