Nail Bed Laceration Repair

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The basic steps for a nail bed laceration repair are: 1) Perform a digital block, 2) Remove the nail, 3) Repair the laceration, 4) Splint the nail bed and nail fold, using the nail if possible. An adequate tourniquet is necessary to maintain a bloodless field. If the nail remains sufficiently intact, clean it and set it aside. Repair the nail bed with an absorbable small suture. When suturing the nail back in place use a non-absorbable suture. You can preload the sutures through the nail before suturing through the digit (as shown). The non-absorbable sutures through the nail can be removed in 2-3 weeks and the old nail will fall off on its own. This should be enough time for a new nail to start growing in. If the nail is not salvageable, you can apply petroleum infused gauze on the nail bed and suture a nail substitute in place of the nail (eg. the suture packaging). This will protect the nail bed and maintain the space between the nail matrix and proximal nail fold to reduce the chance of deformity. The patient should return for a wound check in 2-3 days and follow up with a hand specialist in 1-2 weeks.

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Eric A. -

I've had multiple hand surgeons tell me over the past few years that splinting the nail fold is no longer necessary. It used to be that everyone said to do it, and now my specialists are telling me not to bother.

Any thoughts on this?

Jess Mason -

I've heard and read that too. Sounds like a good option if that's what the patient wants. I think if I'm the patient I'd rather have my nail put back on. It looks more comfortable and cosmetically less deforming for a little while.

Andrew A. -

Are you not setting the pt up for nail bed infection trying to use the nail as a splint over the sutured nail bed. I always thought this was a "bad" idea, even when it was very much in vogue. I opted years ago to bypass this recommendation, as it seemed counter intuitive. As per Eric's comment above even 20 yrs ago, my friends who were hand surgeons told me similarly not to even bother. Nail fold is such a tenuous area to get infected, and now you are adding fb material to the mix.

Also is derma bond on the nail bed not going to inhibit laying down of new tissue, ie slowing wound healing? The nail bed in my mind has a more "mucosal"/ subcutaneous like texture than true epithelized skin. Seems like it is not designed for wound glue

Dennis A. -

What if there is a distal phalanx fracture? let's say, a displaced vs nondisplaced tuft fracture?
Prophylactic antibiotics?

Jess Mason -

The antibiotics question is always a controversial one! I think that yes, I would give antibiotics in that case as it is an open fracture.

Vince R. -

Significant displaced fractures of the mid shaft of the distal phalanx are often seen with nail bed lacerations and can often easily be internally fixed via using a percutaneous 23 gauge needle. You just align the fracture and “skewer” the distal phalanx, and then cut the hub off. Then repair the nail bed laceration. Having a stable underlying base helps support the nail bed injury and prevents major deformity. Add antibiotic cover and remove the needle after about 2 weeks and voila!

Brian F. -

I've heard that removing non-absorbable sutures from nails beds is torture, and so have been advised to use absorbables to re-attach the nail. What do you think about that?

Jess Mason -

I like the idea. Can’t comment on whether or not it’s painful.

Oleg R. -

Are there are any definitive studies about whether placing the nail back to splint the proximal nail fold is actually necessary. Uptodate still lists this in the recommendations. But I also have been told that this is dogma. My podiatry friends take off 100s of nails and never splint the proximal nail fold without any complications and the nail regrows well.

ST -

Anecdotally, some of the hand surgeons at both my academic and community shops have said Dermabond (in lieu of sutures) is fine for simple nail bed repairs, as well as for securing the nail (or foil) in the nail fold.

That said, having used Dermabond on my own hand, that stuff will peel off well before the 2 weeks recommended in the video, so if my consultants were still advocating for nail replacement, I would stick with sutures.

Either way, I like to put the nail back, just for some added protection over the first couple of days of the raw, likely tender, nail bed.

tom f. -

super excellent Jessie
thank you

Brent B. -

Thanks for the awesome videos. I used the same suture location on a recent patient and arranged 24-hr ortho follow-up. The orthopod appreciated the repair but requested that I avoid throwing sutures along the proximal portion of the nail, so to avoid the germinal matrix where new nail production occurs. Their recommendation was to keep all sutures on the sides (lateral portion) of the nail, or use tissue adhesive. I was wondering if anyone else has come across this concern, or had thoughts on this issue? I think its a valid concern and probably one that I'll adopt for future patients. Thank you!

Brent B. -

CorePendium also brings up another concern, which is that suturing through proximal nail plate could disrupt that extensor tendon. Hadn’t thought of this either, but will probably avoid proximal sutures in the future.

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