Injuries to the nail-bed are often associated with damage to other structures that are in the same location. These include fractures of the bone (distal phalanx), fingertip skin and padding (pulp), tendons that straighten or bend the fingertip, and nerve endings.
Usually results from crushing injuries – usually getting the fingertip caught in a door, hit by a hammer or other similar mechanisms. Any type of pinching, crushing, or sharp cut to the fingertip may result in injury to the nail bed.
Simple crushes of the fingertip may result in a painful collection of blood under the nail (subungual haematoma). More severe injuries can result in shearing off of the nail plate, irregular lacerations of the nail bed, loss of nail bed, and possible injuries to the adjacent structures (typically distal phalangeal fractures).
An accurate history of the cause of the injury should be obtained. X-rays are required to assess for associated fractures. The clinical appearance usually underestimates the extent of nail-bed disruption. It is not usually determined until the nail plate is formally removed.
Moderate sized subungual haematoma
Significant nail bed injury noted after removal of nail plate
Nail bed after microsurgical reconstruction
Simple hematomas are drained by making a small hole in the nail in order to relieve the pressure and provide pain relief. Simple lacerations require careful microsurgical alignment of the segments. Associated distal phalangeal fractures are usually aligned after careful reconstruction of the nail bed to which the fragments are attached. Larger fragments of bone may need to be pinned or require splinting to heal the fracture. Missing areas of nail bed can be reconstructed using nail bed flaps or grafts from other digits…usually toes. Usually a synthetic nail-plate is inserted after careful reconstruction.
a. Drainage of a simple subungual haematoma with a hot paperclip.Sudden release of blood and decrease in pain (does not require local anaesthetic – ring block).
b. Microsurgical reconstruction of the nailbed and placement of a synthetic nail plate to allow maximal return of normal contour.
c. Significant nail bed injuries with large fragment distal phalangeal fractures occasionally requires internal fixation as part of the nail bed reconstruction.
The final appearance and function of the nail and surrounding structures depends on the ability to restore the normal anatomy. If the injury is sharp and can be repaired, a normal nail is likely. If there is more severe crushing of the nail bed, then there is a greater likelihood of nail bed scarring and subsequent deformity of the nail. It normally takes up to 6 months for the final nail appearance to be established.
Loss of part or all of the nail bed can be reconstructed with grafts from other digits…..usually from the nail bed of a toe to prevent further injury or deformity of the fingers. It is usually harvested as a split-thickness graft to reconstruct a missing nail bed.
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