Nail Bed Injuries of the Finger

Tetanus Toxoid Intravenous Antibiotics Elevation of the Limb


  1. Paronychial skin (skin around nail plate).
  2. The pulp (volar side of the finger).
  3. The nail bed (the tissue under the nail bed). Further distinction can be made between the germinal matrix (white part of nail bed also called the lunula) and the sterile matrix, which is the distal part of the nail.
  4. Distal phalanx fractures.
  5. The nail plate can be lifted out of nail bed proximally and is commonly associated with a distal phalanx fracture (seymour fracture).
Fingernail bed diagram

Initial Management

  1. Consider that most nail bed injuries are associated with distal phalanx fractures and should be treated as open fractures.
  2. Tetanus prophylaxis.
  3. Prophylactic antibiotics (Cefazolin).
  4. Irrigate wound with saline and cover with a dressing like adaptic or vaseline gauze.
  5. Keep the nail plate or parts of it in a wet saline swab and do not discard it.


Definitive Management

  1. Nail bed lacerations and subungual hematomas larger than 50% of nail plate surface are generally treated with surgical repair. This repair is usually done with a microsurgical technique.
  2. Distal phalanx fractures are usually transfixed with K-wires across the distal inter-phalangeal joint.
  3. Nail plates that are lifted out of the proximal nail fold should be replaced surgically back into nail fold.
  4. It takes approximately 100 days for the nail to grow back completely. Nail bed laceration repairs endeavour to prevent nail plate deformities.


Rehabilitation

  1. The fingertip is protected with a circumferential thermoplastic splint for two to three weeks, until the wound has healed.
  2. Most fingertip injuries are associated with digital nerve injuries and will benefit from desensitisation after wound healing.
  3. Therapy will include scar management and oedema control with pressure garments to shape the tip of the finger and facilitate movement.
  4. Early mobilisation of the finger and especially the distal inter-phalangeal joint is crucial to prevent limitation in range of movement.