Nailbed Injuries

Nailbed Injuries

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Nailbed injuries are common, with fingertip injuries being the most often seen type of hand injuries. The fingertip is frequently injured because it is the point of interaction between the body and one’s surroundings in the majority of activities performed on a daily basis, and it is the most distal portion of the upper extremities. [1, 2, 3, 4, 5, 6]

In addition to long-term cosmetic consequences, injuries to the nail can affect daily living. The nail provides protection for the fingertip, offers the ability to pick up small objects, and plays a role in tactile sensation. It serves as a counter force when the finger pad touches an object; two-point discrimination distance widens substantially with removal of a nail.

Blunt trauma to the fingertip and nailbed requires adequate treatment to prevent secondary deformities and reduce the need for subsequent reconstruction. [7] Delayed or inadequate treatment can result in negative functional and cosmetic outcomes. Peak incidence of fingertip and nailbed injuries is from 4 to 30 years of age. According to Chang et al, 10% of such accidents are treated in the emergency department. In the case of fingertip injuries, the nailbed is injured in 15-24% of cases. [8]

The injured finger can usually be examined without anesthesia, although children or those in severe pain may require a digital block first. A complete examination of sensation (performed prior to a digital block), motor function, and vascular supply is necessary.

A digital block of 1% lidocaine hydrochloride without epinephrine provides anesthesia of sufficient duration for most repairs. Bupivacaine extends anesthesia time 4-8 hours for longer procedures. Children may require procedural sedation and analgesia.

Observe the posture of the fingers, and look for any presence of deformities signifying fracture, dislocation, or tendon avulsion, and the presence of glass, wood, metal, or other foreign body fragments.

Depending on the extent of injury, radiologic evaluation with anteroposterior, lateral, and oblique views of the injured finger(s) may be useful to rule out foreign bodies and fractures or dislocations of the distal finger. [6]

The prophylactic use of antibiotics is indicated, depending on mechanism and extent of injury, such as for crush injuries and human bites or animal bites. Many clinicians prescribe a first-generation cephalosporin when bone or joint is exposed below a nailbed injury.

Small (less than 25% of the nailbed) and painless subungual hematomas require no intervention, as the hematoma will eventually reabsorb. If the subungual hematoma covers more than 25% of the nailbed or is causing pain, the patient should be offered evacuation via trephination or nail removal (see Hand, Subungual Hematoma Drainage).

Lacerations to the nailbed should be repaired using 6-0 or smaller absorbable sutures. Minimal to no debridement should be performed because aggressive debridement may cause undue tension on the repair and results in scarring.

When repairing avulsed nails and nailbeds, if the nail is detached proximally, it must be removed to inspect for any damage to the nailbed.

See the treatment images below.

Crush and avulsion injuries, as well as injuries associated with distal phalanx fractures, have a worse prognosis.

See 15 Fingernail Abnormalities: Nail the Diagnosis, a Critical Images slideshow, to help identify conditions associated with various nail abnormalities.

To fully appreciate the consequences and treatment of nailbed injuries, reviewing the anatomy of the nailbed and the surrounding tissues is useful. [1, 9, 10, 11]

Nail – Hard structure composed of desiccated, keratinized squamous cells

Perionychium – Composed of the nailbed and paronychia

Nailbed – Soft tissue below the nail that is bound to the underlying periosteum of the distal phalanx and consists of the germinal and sterile matrix [11]

Paronychia – Lateral nail folds

Hyponychium – Junction between the nailbed and fingertip skin that contains large numbers of polymorphonuclear leukocytes and lymphocytes, which protect the subungual tissue from infection

Nail fold – Holds the proximal nail

Eponychium – Commonly known as the cuticle, or the distal portion of the nail fold where it attaches to the dorsum of the nail

Lunula – White opacity distal to the eponychium, caused by the presence of nail cell nuclei in the germinal matrix as they stream upward and distally to create nail

Nail formation is a collective production by 3 areas of the perionychium:

The germinal (intermediate) matrix, covering the ventral floor of the proximal volar nail fold to the lunula, produces 90% of nail volume. It is immediately distal to the extensor tendon attachment to the distal phalanx. As the cells are produced, they force cells ahead to flatten and stream distally into the nail because of the confining boundaries of the nail fold. The nuclei of the cells disintegrate as they grow beyond the lunula, giving the nail its clear appearance.

The sterile (ventral) matrix begins as the lunula ends and extends out to the hyponychium. It is closely adherent to the dorsal periosteum of the distal phalanx. It contributes a small amount to the nail but mostly provides adherence between the nail and the nailbed.

The proximal half of the dorsal roof of the nail fold produces cells that give the nail its shine.

Longitudinal nail growth takes between 70 and 160 days to cover the entire length of the nail. After an injury, nail growth is stunted or absent for up to 21 days. The nail then grows rapidly for approximately the next 50 days and then slows again before a normal and sustained growth rate resumes. These relative accelerations and slowdowns in nail growth create the characteristic lump that is often observed on most nails that regrow after trauma.

As a result of scar tissue being unable to produce nail material, damage to specific components of the perionychium will lead to characteristic defects during regrowth of the posttraumatic nail. A scar of the dorsal roof of the nail fold creates a dull streak on the nail surface, while a scar of the germinal matrix may cause a split or absent nail, and a scar in the sterile matrix results in a split or nonadherent nail beyond the scar.

The nailbed is supplied by two volar arterial arches that are anastomoses between digital arteries of the finger or toe, just above the periosteum of the distal phalanx. Venous drainage coalesces in the proximal nailbed and proximal to the nail fold and drains over the dorsum of the finger. Abundant lymphatic vessels are present in the nailbed. The perionychium is innervated by the dorsal branches of the paired digital nerves, one to the nail fold, one to the fingertip, and one to the pulp.

The hand is involved in 11-14% of on-the-job injuries and 10% of all accident cases in US emergency departments. However, the exact prevalence of nailbed injuries is unknown since many patients with nailbed injuries do not bother to seek a physician’s care for what they perceive as a minor trauma.

Complications of nailbed injuries include nail loss, abnormal growth, nonadherence of new nail, splitting of the nail, soft tissue infection, and osteomyelitis of the underlying distal tuft.

A 3:1 male-to-female predominance of injury exists.

Nailbed injuries occur in people of all ages; however, the most common age group is between 4 and 30 years old. Fingertip injuries account for two thirds of hand injuries in children, and damage to the nailbed occurs in 15-24% of these injuries. [2, 3]

Nailbed injuries generally heal well with appropriate treatment, although it may take months to years for the nail to grow back into the proper shape.

Crush and avulsion injuries, as well as injuries associated with distal phalanx fractures, have a worse prognosis. Injuries that span the entire nailbed or most of the bed and fold also fare worse than those that are isolated to one to two thirds of the nailbed or only to the nail fold and germinal matrix.

All patients should be advised that a deformed nail is a possibility.

New nail growth may take from 3-12 months and even then, it may be misshapen for a longer time.

If problems with new nail growth exist at 6 or 12 months, patients may want to follow up with a hand surgeon for possible scar excision or nailbed revisions.

For excellent patient education resources, visit eMedicineHealth’s Skin Conditions and Beauty Center. Also, see eMedicineHealth’s patient education article Subungual Hematoma (Bleeding Under Nail).

Brown RE. Acute nail bed injuries. Hand Clin. 2002 Nov. 18(4):561-75. [Medline].

Inglefield CJ, D’Arcangelo M, Kolhe PS. Injuries to the nail bed in childhood. J Hand Surg [Br]. 1995 Apr. 20(2):258-61. [Medline].

de Alwis W. Fingertip Injuries. Emerg Med Australas. 2006 Jun. 18(3):229-37. [Medline].

Van Beek AL, Kassan MA, Adson MH, Dale V. Management of acute fingernail injuries. Hand Clin. 1990 Feb. 6(1):23-35; discussion 37-8. [Medline].

Loréa P. Primary care of nail traumas. Chir Main. 2013 Jun. 32 (3):129-35. [Medline].

Tully AS, Trayes KP, Studdiford JS. Evaluation of nail abnormalities. Am Fam Physician. 2012 Apr 15. 85 (8):779-87. [Medline].

Nanninga GL, de Leur K, van den Boom AL, de Vries MR, van Ginhoven TM. Case report of nail bed injury after blunt trauma; what lies beneath the nail?. Int J Surg Case Rep. 2015. 15:133-6. [Medline].

Chang J, Vernadakis AJ, McClellan WT. Fingertip injuries. Clin Occup Environ Med. 2006. 5 (2):413-22, ix. [Medline].

Zook EG. Anatomy and physiology of the perionychium. Hand Clin. 1990 Feb. 6(1):1-7. [Medline].

Zook EG. Understanding the perionychium. J Hand Ther. 2000 Oct-Dec. 13(4):269-75. [Medline].

Haneke E. Anatomy of the nail unit and the nail biopsy. Semin Cutan Med Surg. 2015 Jun. 34 (2):95-100. [Medline].

Guy RJ. The etiologies and mechanisms of nail bed injuries. Hand Clin. 1990 Feb. 6(1):9-19; discussion 21. [Medline].

Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg [Am]. 1999 Nov. 24(6):1166-70. [Medline].

Gaston RG, Chadderdon C. Phalangeal fractures: displaced/nondisplaced. Hand Clin. Aug 2012. 28(3):395-401. [Medline].

Gungor F, Akyol KC, Eken C, Kesapli M, Beydilli I, Akcimen M. The value of point-of-care ultrasound for detecting nail bed injury in ED. Am J Emerg Med. 2016 Sep. 34 (9):1850-4. [Medline].

Mignemi ME, Unruh KP, Lee DH. Controversies in the treatment of nail bed injuries. J Hand Surg Am. 2013 Jul. 38 (7):1427-30. [Medline].

Simon RR, Wolgin M. Subungual hematoma: association with occult laceration requiring repair. Am J Emerg Med. Jul 1987. 5(4):302-4. [Medline].

Mignemi ME, Unruh KP, Lee DH. Controversies in the treatment of nail bed injuries. J Hand Surg Am. 2013 Jul. 38 (7):1427-30. [Medline].

Garcia-Rodriguez JA. Draining a subungual hematoma: procedures and assessments video series. Can Fam Physician. 2013 Aug. 59 (8):853. [Medline].

Patel L. Management of simple nail bed lacerations and subungual hematomas in the emergency department. Pediatr Emerg Care. 2014 Oct. 30 (10):742-5; quiz 746-8. [Medline].

Meek S, White M. Subungual haematomas: is simple trephining enough?. J Accid Emerg Med. 1998 Jul. 15(4):269-71. [Medline].

Seaberg DC, Angelos WJ, Paris PM. Treatment of subungual hematomas with nail trephination: a prospective study. Am J Emerg Med. May 1991. 9(3):209-10. [Medline].

Lankford HV. Subungual Hematoma in the Mountains. Wilderness Environ Med. 2016 Mar. 27 (1):164. [Medline].

Tzeng YS. Use of an 18-gauge needle to evacuate subungual hematomas. J Emerg Med. Jan 2013. 44(1):196-7. [Medline].

Kaya TI, Tursen U, Baz K, Ikizoglu G. Extra-Fine Insulin Syringe Needle: An Excellent Instrument for the Evacuation of Subungual Hematoma. Dermatol Surg. 2003 Nov. 29(11):1141-3. [Medline].

Kain N, Koshy O. Evacuation of subungual haematomas using punch biopsy. J Plast Reconstr Aesthet Surg. Nov 2010. 63(11):1932-3. [Medline].

Khan MA, West E, Tyler M. Two millimetre biopsy punch: a painless and practical instrument for evacuation of subungual haematomas in adults and children. J Hand Surg Eur. Sep 2011. 36(7):615-7. [Medline].

O’Shaughnessy M, McCann J, O’Connor TP, Condon KC. Nail re-growth in fingertip injuries. Ir Med J. December 1990. 83:136-7. [Medline].

Miranda BH, Vokshi I, Milroy CJ. Pediatric nailbed repair study: nail replacement increases morbidity. Plast Reconstr Surg. April 2012. 129:1028. [Medline].

Harrison BP, Hilliard MW. Emergency department evaluation and treatment of hand injuries. Emerg Med Clin North Am. 1999 Nov. 17(4):793-822. [Medline].

Jeys LM, Khafagy R. A useful technique for securing nails: the figure-of-eight suture. Br J Plast Surg. 2001 Oct. 54(7):651. [Medline].

Shaw A, Findlay J, Kulkarni M. Management of fingertip and nail bed injuries. Br J Hosp Med (Lond). 2011 Aug. 72 (8):M114-8. [Medline].

Hallock GG. Expanded applications for octyl-2-cyanoacrylate as a tissue adhesive. Ann Plast Surg. 2001 Feb. 46(2):185-9. [Medline].

Edwards S, Parkinson L. Is Fixing Pediatric Nail Bed Injuries With Medical Adhesives as Effective as Suturing?: A Review of the Literature. Pediatr Emerg Care. 2016 Dec 12. [Medline].

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]. Feb 2008. 33(2):250-3. [Medline].

Richards AM, Crick A, Cole RP. A novel method of securing the nail following nail bed repair. Plast Reconstr Surg. 1999 Jun. 103(7):1983-5. [Medline].

Hallock GG, Lutz DA. Octyl-2-Cyanoacrylate adhesive for rapid nail plate restoration. J Hand Surg [Am]. 2000 Sep. 25(5):979-81. [Medline].

Pasapula C, Strick M. The use of chloramphenicol ointment as an adhesive for replacement of the nailplate after simple nail bed repairs. J Hand Surg [Br]. 2004 Dec. 29(6):634-5. [Medline].

Purcell EM, Hussain M, McCann J. Fashionable splint for nailbed lacerations: the acrylic nail. Plast Reconstr Surg. 2003 Jul. 112(1):337-8. [Medline].

Etoz A, Kahraman A, Ozgenel Y. Nail bed secured with a syringe splint. Plast Reconstr Surg. 2004 Nov. 114(6):1682-3. [Medline].

Bayraktar A, Ozcan M. A nasogastric catheter splint for a nailbed. Ann Plast Surg. 2006 Jul. 57(1):120. [Medline].

Yang J, Wang T, Yu C, Gu Y, Jia X. Reconstruction of large area defect of the nail bed by cross finger fascial flap combined with split-thickness toe nail bed graft: A new surgical method. Medicine (Baltimore). 2017 Feb. 96 (6):e6048. [Medline].

Darrell Sutijono, MD Attending Physician, Department of Emergency Medicine, Kaiser Permanente Santa Clara Medical Center

Darrell Sutijono, MD is a member of the following medical societies: American College of Emergency Physicians, American Institute of Ultrasound in Medicine

Disclosure: Nothing to disclose.

Mark A Silverberg, MD, MMB, FACEP Assistant Professor, Associate Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate Medical Center

Mark A Silverberg, MD, MMB, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Eric M Kardon, MD, FACEP Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center

Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Medical Association of Georgia

Disclosure: Nothing to disclose.

Tom Scaletta, MD President, Smart-ER (; Chair, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine

Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Nailbed Injuries

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