A 12-year-old boy presented after a fall from his bicycle with an injury to his right long finger.  Should the nail be removed? Should the nail be replaced?

Tailoring Treatment for Nail Bed Trauma

Figure 1. Crush injury to distal phalanx with laceration and subungual hematoma. Photos: David Effron, MD. (Click to enlarge.)

Nail bed injuries vary in complexity from a simple subungual hematoma to a complex open fracture with nail bed laceration. Management should be tailored to the extent of the injury and underlying fracture.

Clinical assessment will guide management. Many patients with nail bed injuries—more than 50 percent—have an associated fracture. Radiographs should be obtained to assess any bony injury.¹ Outcomes are dependent on presence of fracture and degree of deformity.² The Fingertip Injuries Outcome Assessment Score can guide prognosis after fingertip amputations (see table below). A score of 12 or less is considered excellent and a score of 13 to 18 is considered good. In pediatric patients, care should be taken to identify a Seymour fracture, a displaced distal phalangeal physeal fracture with associated nail bed injury. This fracture requires antibiotics and may require operative management, including open reduction and pinning.³

Simple subungual hematomas involving less than 50 percent of the nail area can be managed with trephination alone.^4-6  Management of larger subungual hematomas is controversial. One study found that with intact nail margins, decompression alone had similar outcomes to nail removal and exploration.⁷

Figure 2. After trephination and laceration repair with tissue adhesive. (Click to enlarge.)

The medical literature includes conflicting recommendations regarding the management of nail bed injuries. Nail removal is generally recommended in cases involving nail margin disruption, significant swelling, or displaced fracture.⁸  For simple nail bed lacerations, repair with tissue adhesive has similar outcomes to suture repair.^9-11  Some authors recommend nail bed repair without subsequent nail replacement.^12-14  A recent study demonstrated similar outcomes with or without nail replacement after nail bed repair.¹⁵ Some authors believe that nail replacement may serve as a dressing and splint to ensure proper healing and nail growth. Replacement with the native nail is preferable to an artificial splint.¹⁶ If the nail is not available, a splint may be created using chromic suture foil, which can be inserted in the nail fold.

No single treatment strategy applies to all nail bed injuries. Repair and dressing should be tailored to the individual patient, based on assessment of hematoma, laceration, fracture, deformity, and expected prognosis. Patients should be counseled that nail deformity may be permanent or temporary; the nail may take three to 12 months to fully grow and heal.