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Duke Orthopaedics
presents
Wheeless' Textbook of Orthopaedics

Nail Bed Injury / Pathology


- See:
       - Distal Phalangeal Frx:
       - Finger Tip Injuries:
       - Ingrown Toe Nail
       - Paronychia:
       - Matriectomy:
       - Mucous Cyst:
       - Nail Bed Biopsies:

- Anatomy:
      - nail plate:
         - comprised of concentrated, adherent interdigitating cells which have no nuclei or organelles;
    - germinal matrix:
         - comprised of cells which contribute to 90% growth of the new nail;
         - distal edge of the germinal matrix is demarcated by the edge of lunula;
         - there is minimal adherence of germinal matrix to the nail;
    - sterile matrix:
         - extends distal to the lunula;
         - responsible for adherence of nail to nail bed;

- Nail Bed Injuries:
    - w/ nail bed injuries, especially crushing ones, may seem innocuous but must be treated appropriately to minimize subsequent deformity;
    - force of flat nail is transmitted to prominence of underlying tuft, concentrating the pressure in that area, causing a bursting laceration to 
          occur in the nail matrix;

- Treatment: Nail Plate Intact:
    - recognition of nail bed laceration can be difficult, but the acute setting is the best opportunity to avoid deformity;
    - consider exploration of the entire nail bed if a subungual hematoma involving more than 25% of the nail is present esp if frx is present;
    - nail is removed & matrix carefully sutured;

- Treatment: Nail Bed Avulsed:
     - nail bed laceration is visible;
     - need for repair of the nail bed is clearly evident;
     - consider insertion of petroleum gauze between the nail fold and the matrix to prevent adhesions;

- Nail Bed Injuries w/ Distal Phalangeal Frx:
    - see: distal phalangeal frx:
    - crushing injuries may cause fractures, with or w/o soft tissue injury;
    - small, non displaced tuft frx do not require treatment;
    - diaphyseal frxs often result in angulation & malalignment, which may result in considerable deformity;
          - often these frxs can be simply stabilized by suturing the skin of the lateral nail folds;
          - more unstable frxs need to be stabilized w/ K wires;
    - note that base of nail bed and soft tissue may become entrapped in frx site;
          - commonly seen where the root of the nail has been avulsed from beneath the proximal nail fold;
          - if this is not adressed nonunion of the fracture may result;

- Preop Considerations:

- Techique of Total Nail Plate Avulsion:

- Repair Technique:
    - exposure of nail matrix and nail fold
          - indicated only for proximal nail injuries;
    - if the lateral cuticle has been injured, repair it first (w/ 5-0 nylon) inorder to align the rest of the nail;
    - nail bed laceration is then carefully re-approximated w/ 6-0 or 7-0 chromic or Vicryl Sutures;
    - w/ proximal avulsion of the germinal matrix, direct suture repair can be difficult;
         - consider placing a horizontal matress suture thru each corner of the of the germinal matrix which is then passed upwards through the 
                lateral ends of the epinychial corners


Nail bed repair and reconstruction by reverse dermal grafts.

Treatment of subungual hematomas with nail trephination: a prospective study.

Injuries to the nail bed in childhood.

Anatomy and physiology of the perionychium: a review of the literature and anatomic study.

A study of Nail Bed Injuries: causes, treatment, and prognosis

A Prospective, Randomized, Controlled Trial of 2-Octylcyanoacrylate Versus Suture Repair for Nail Bed Injuries




Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Friday, May 11, 2012 1:52 pm