II. Management: Nail Injury
- See Nail Injury
- Retain the native nail
- Acts as a splint and protects the nail bed
- Avoid artificial nail splints due deformity risk and infection (use the native nail instead)
- Reattach partially avulsed or fully avulsed nails
- Option 1: Tack down nail edge at each Paronychial fold
- Hold nail in place with a 1-2 Sutures through nail and the adjacent lateral nail folds (Paronychial fold)
- Risk of nail sliding out from the eponychial fold (proximally) and Paronychial folds (laterally)
- Option 2: Transverse figure of eight technique
- Indicated for nail reattachment
- Soak the nail in warm saline for 15 minutes
- Cut two 1 mm wedges into the distal nail edge (similar to the top of a king's crown)
- Suture the nail to hold it in place
- Place first Suture throw adjacent to one lateral nail edge, from distal to proximal
- Pull the Suture from proximal nail edge, across the nail diagonally to distal notch
- Thread the Suture around the distal nail to the second notch
- Place the second Suture throw from the other lateral nail edge, from distal to proximal
- Pull the Suture from the proximal nail edge across the nail diagonally to the start of the Suture
- Tie off the Suture
- Option 1: Tack down nail edge at each Paronychial fold
- Repair nail bed if indicated
- See Nail Bed Laceration
- Indications
- Subungual Hematoma >50% of nail bed AND
- Nail detached or surrounding tissue disrupted (especially at proximal nail at the germinal matrix)
- Repair
- Remove nail attempting to keep intact for later Splinting
- Use Absorbable Suture (e.g. Chromic 6-0)
- Alternatively, Tissue Adhesive has been used in small studies to close nailbed Lacerations with similar outcomes
- Nail Replacement
- Replace nail to serve as splint, protect the nail bed and stent the eponychial fold
- Avoid using artificial nail splints due deformity risk and infection
- Nail Replacement after nail bed repair was associated with increased infection risk and delayed healing in children
III. Management: General principles
- Control bleeding
- Control pain
- Preserve finger length
- Critical for thumb, index, and middle finger function
- Avoid tight, excessive tension of a finger tip closure
- Excessive skin tension at the finger tip is a risk for hook nail
- Ronger end of distal phalanx if it protrudes beyond soft tissue
- Healing by Secondary Intention is preferred if skin is inadequate to close wound without tension
- Treatment of finger injury is directed at coverage
- Do not close major wounds by secondary intention
- Epithelization is delayed 12 weeks
- Results in thin, tender overlying skin
- Do not close major wounds by secondary intention
- Repair tendon injuries
- Consult orthopedics if unable to repair injury
- Protect wound site if repair at other facility
IV. Management: Types of Closure
- Simple
- Keep scar line on dorsal surface as much as possible
- Prevents a tender scar
- Never trim dog ears (may compromise healing)
- Keep scar line on dorsal surface as much as possible
- Epithelialization (Healing by Secondary Intention)
- Free Grafts
- Flap Grafts
- Occassionally used by experienced surgeon)
- Indicated when subcutaneous tissue needed
- Grafting over bone or tendon