by Nail Trauma
Brief Anatomy Overview:
Topics to discuss:
-Acrylic Nail Injury
-Subungual Hematoma management
-Nail Bed Injuries and management
– cosmetic importance, prevent infection, enhance tactile sensation, enhancement of picking up objects, protects digits from mechanical injuries
Why Should we care?
1) Acrylic Nail Injury
21 year old female presents to ED with “broken nail.” Patient had acrylic nails placed 2 weeks ago and accidentally slammed her right thumb into car door 2 hours ago, and heard a crack. She noticed bleeding at the site, and stated that the nail looked like it was about to fall off.
What is your management?
-Do a complete exam, making sure hand/digits are neurovascularly intact.
-Order XR to rule out fracture.
-Pain control – Motrin/Tylenol, will probably need a digital block if you are trying to remove the nail or do any laceration repair
Okay great no fracture. Now what? How do you get the artificial nail off? How do you know if the nail bed is compromised? How do you know the biological nail is not fallen off with the artificial nail?
First perform a digital block if you are considering any manipulation. Get the patient as comfortable and pain free as you can. Next, you will need warm acetone. Nail glues usually consist of ethyl cyanoacrylate or polyurethane acrylate. Acetone is great to dissolve this glue. Get a large basin and fill it with warm water. Next get a cup and fill it with acetone (clean urine cup is fine) and let the acetone in the cup warm up in the warm water basin for 10min. Cut off the artificial nail as close to digit as possible. Next, have the patient soak the affected digit in the warmed acetone cup. This may sting/burn (but that’s why we did the digital block). Reassess every 10-15min.
Once the artificial nail is off, you can see the extent of damage. Did the biological nail come off as well? Is the nail bed lacerated? (More on this in Section 3).
What if you don’t have acetone in the ED/pharmacy? Warm water with hand soap is also an option, but takes longer, will need to reassess every 15min.
2) Subungual Hematoma
No indications for trephination if <25% of entire nail size, no significant pain, or if injury occurred over 24h ago (blood would have likely clotted and not flow out).
-If you have an indication to trephinate, you can use a trephinator machine. Other options include heated paper clip, 23-gauge needle (twist and rotate needle back & forth), 11 blade
-If hematoma >50%, significant pain, blood underneath cuticles, will need to remove entire nail as a deeper injury is likely. Will need pain control and digital block!
– Get an XR for ruling out fractures
-Tetanus vaccine, may consider antibiotics but weak evidence
3) Nail Bed Injury & Repair
Nail bed injury + fracture = open fracture, will need ortho evaluation
If suspected nail bed injury that needs to be repaired, you will need to remove the nail to do this. Provide patient with adequate pain control and digital block. Place affected digit in warm water to soften the nail first, then remove.
Laceration repair – absorbable sutures 5.0 or 6.0s. May opt for dermabond if the laceration is linear (if it looks too complicated, just suture), a study in 2008 with orthopedic residents showed it had similar cosmetic and functional outcomes (40 patients in the study). If you do decide dermabond, make sure hemostasis is achieved otherwise it won’t work.
-After repair, you generally want to replace the nail back onto the digit (via sutures 3-4.0 Nylons). Why? You want to keep the space between the cuticle (eponychium) and nail bed where the nail will grow. If this space is occluded or scarred off, nail won’t grow. Takes about 6months for a nail to fully form.
Figure 8 style technique to suture nail back into place. You will need to create holes to secure it down. If you don’t have time to suture, you can opt for something artificial. Petroleum gauze will work. The concept is to protect the nail bed and preserve space for new nail to grow.
Anything that is complicated or if you’re not sure then ortho/hand surgery consult is appropriate.
Boostrix, +/- antibiotics, have patient follow up in 3-5days for wound check and remove sutures in 2 weeks. Sources
https://www.nuemblog.com/blog/2018/4/1/nail-traumas
