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Nail bed injury
This document summarizes key information from a seminar presentation on nail bed injuries by Dr. Prajwal K Rao. It discusses the anatomy of the nail unit, causes of nail bed injuries which commonly involve long fingers in males aged 4-30. Clinical examination involves sensory and pattern evaluation as well as matrix involvement. Imaging can include x-rays. Injuries are classified and trephination may help reduce pain. Nail bed repair indications and techniques are outlined, including options when the nail is unavailable. Post-operative care and potential complications are also summarized.
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Nail bed injury
- 1. NAIL BED INJURY SEMINARPRESENTATION Dr Prajwal K Rao
- 3. Anatomy • Perinochyium –Nail, Nail bed, Surrounding skin • Paronychium – Lateral nail folds • Hyponychium – Skin distal and palmar to nail • Eponychium – Dorsal nail fold • Lunula • Matrix - Sterile and Germinal
- 4. • Germinal Matrix– Production of Nail Plate • Sterile Matrix – Adds Squamous cells to Nail • Dorsal Roof Matrix – Luster of Nail Plate • Nail growth is 0.1mm/day
- 5. Nail bed Injury •75% males • Long fingers commonly involved • Common age : 4-30 years • Cause – Deforming Force
- 6. Clinical examination • Sensoryexamination • Pattern of nail bed laceration • Involvement of germinal and dorsal roof matrix • Associated Subtotal Pulp amputation
- 7. Imaging • AP, Lateraland Oblique views of injured fingers.
- 8. Classification • Subungual hematoma •Simple lacerations • Stellate lacerations • Severe Crush • Avulsion
- 10. Trephination • Helps toreduce pain, do not fasten healing process • Drainage of hematoma by perforation if < 50 % of nail involved. • Nail removal, Debridement and Nail bed repair if >50 % of nail involved
- 12.
- 13. Indications for Nailbed repair • Open nail bed laceration • Closed nail bed laceration with Subungual hematoma involving > 50 percent of nail • Closed nail bed laceration with displaced distal phalangeal fracture
- 14. Positioning and Exposure •Under tourniquet control and Local anesthesia • Freer elevator inserted b/w nail plate and nail bed from distal to proximal
- 15. • Elevation ofdorsal roof matrix to expose laceration under nail fold or germinal matrix
- 16. Procedure • Step 1– Under Loupe magnification -> Minimal debridement and irrigation • Step 2 – Tension free repair of nail bed using absorbable 6-0,7-0 suture or Dermabond • Step 3 – Nail is replaced back to nail fold and suture taken from nail to Hyponychium
- 18. • If nailis not available! OPTIONS: • Artificial Silicone nail • Suture Package Remember to make couple of holes in the nail
- 19. • 5 mmof visible nail – aesthetically acceptable. • Nail bed is preserved as much as possible as it gives the finger the sense of completeness. • If short nail bed / partial injury to germinal matrix -> excise the whole germinal matrix.
- 20. Nail bed graft Lossof nail bed or gap more than 4 to 5mm. Loss of sterile matrix • Split Thickness Sterile Matrix Graft, from adjacent nail bed, amputed fingers or great toe. Loss of Germinal Matrix • Full thickness graft • Free toe pulp including nail complex
- 22. Avulsion laceration • Cause:High energy injuries • Associated condition: Distal phalanx fracture • Treatment: Nail removal, Nail bed repair with +/- fixation. If there is significant loss of nail matrix then split thickness graft or nail matrix transfer is done.
- 23.
- 24. • Step 1–> Nail bed flap reduced back and Splint in nail fold • Step 2 –> Elevate dorsal roof matrix, Pass 5-0 nonabsorbable suture from dorsum, horizontal bite on nail bed and brought back to dorsum and held in mosquito forceps. • Step 3 –> 2 or 3sutures passed, then these sutures are tied on the dorsum, reducing the nailbed.
- 26. Tuft fracture • Nailinjury in combination with finger tip fracture. Options: • Repair of nail bed and placing nail back on the bed. • K wire through the medullary cavity.
- 27. Postoperative Care • Nonadherent dressing • Finger splint immobilizing DIP joint • Complete first nail regeneration takes 4 to 6 months with lack of sheen. • Quality of nail depends on initial injury to matrix and age of patient.
- 28. Complications • Hook nail– due to advancement of nail matrix to obtain coverage without adequate bony support. • Nail Ridge • Split nail – caused by scarring of matrix.
- 30. • Non adherence(onycholysis) • Nail absence • Cornified nail bed • Nail spikes/cysts
- 31.
- 32.
Editor's Notes
- #3 Nail – Hard structure composed of dessicated, keratinised, squamous cells attached to nail bed. Nail loosely attached to Germinal matrix and Densely adherent to Sterile Matrix and eponychium.
- #15 1 to 2 mm beyond laceration is elevated Undersurface of nail is examined for nail bed remnants
- #17 Nail – Splint for tuft fractures, Prevents dressing from adhering, Prevents synechiae b/w germinal matrix and dorsal roof matrix.
- #20 Small nail, nail cyst
- #24 Laceration over GM at prox nail bed, and distal GM prolapses out of nailfold.