The nail is removed with a periosteal elevator or iris scissors. After exsanguination, a finger tourniquet is placed around the proximal phalanx to allow for hemostasis and adequate visualization of the nail bed. The finger and often the entire hand are surgically prepared and draped. Lidocaine with epinephrine (1 : 100,000) has also been shown to be safe for digital blocks. A finger block is performed with 1% plain lidocaine. This discussion on nail bed repair includes the various points pertinent for treatment of simple lacerations, crush injuries, and avulsion injuries. If the nail is broken or the edges are disrupted, we recommend removal of the nail with exploration and repair of the nail bed. Generally, if the nail edges are intact, we recommend drainage only. At the present time, the decision for removal of the nail is based primarily on evaluation of the nail edges, rather than the percentage of hematoma. Our cutoff for nail removal and repair subsequently became greater than 50%. However, a prospective 2-year study of 48 patients with hematomas showed no complications of nail deformity with drainage only, regardless of hematoma size or the presence of a distal phalangeal fracture. In the past, we recommended removal of the nail and repair of the nail bed if greater than 25% to 50% of the nail was undermined by blood. B, The authors’ preferred method of burning a hole through the nail is with an ophthalmic battery-powered cautery. The hole must be large enough to allow continued drainage otherwise, the hematoma recurs if a clot seals the hole.Ī, A time-honored method of burning a hole through the nail is with a heated paperclip. The heated tip is passed through the nail and is cooled by the hematoma, avoiding injury to the nail bed. We prefer a battery-powered microcautery unit, available in most emergency departments ( Figure 9.4 ). Trephination of the nail has been performed with drills, needles, and paperclips heated in an open flame until red hot. We prefer a povidone-iodine (Betadine) soap scrub. Surgical preparation is essential to decrease the chance of bacterial inoculation of the subungual space on trephination of the nail. If the nail is intact, the pressure of the blood within this confined space frequently causes severe throbbing pain, and evacuation of the hematoma is indicated.īefore evacuation of the hematoma, the finger should be surgically prepared. Because of the inability to see the extent of the nail bed laceration, subungual hematomas can be the most challenging injury to treat.Ĭompression of the nail onto the underlying distal phalanx can lead to a laceration in the nail bed and bleeding beneath the nail, known as subungual hematoma. A fifth category of injury is subungual hematoma. These injuries occur in the same order of frequency. Most nail bed trauma falls into the classification of simple lacerations, stellate lacerations, severe crush, or avulsions ( Figure 9.3 ). Similarly, the most distal part of the nail bed is the most frequently injured part of the perionychium, and often the hyponychium is involved as well. The long finger is most frequently injured because of its increased exposure distal to the other digits. Patients are most often older children or young adults. We recommend a radiograph of the involved finger because of the 50% chance of fracture with a nail bed injury.ĭoors are the most common source of trauma to the perionychium, followed by smashing the finger between two objects and lacerations from yard or workshop tools. Evaluation of an injured perionychium includes assessment for associated injuries. In the case of fingertip injuries, evaluation of the perionychium usually begins in the office or emergency department with the patient history.
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