Which surgical techniques are used in the repair of nailbed injuries?

Updated: Sep 27, 2017
  • Author: Darrell Sutijono, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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When repairing avulsed nails and nailbeds, if the nail is detached proximally, it must be removed to inspect for any damage to the nailbed. Careful inspection of the nail is important because often only a fragment of nailbed may be attached to the undersurface of the avulsed nail. Only outer and dorsal surfaces of the nail should be cleaned. Any large fragments of nailbed should be preserved for use as a free graft. Crushing injuries leave many small pieces of nailbed. If all fragments are not incorporated into the repair, they may grow independently and cause nail horns or spicules. If tissue is not available and the defect is small enough, the area will heal effectively by secondary intention.

Simple dorsal roof lacerations can often be repaired by accurately repairing the skin overlying the nail fold. However, if possible, suturing of the dorsal roof with a 7-0 chromic suture may provide more accurate repair. Associated paronychial injuries must be repaired and stented to prevent pterygium or adhesions, as it serves as a mold to coax nail to grow along a proper path. Distal phalangeal fracture reduction and healing is important to final nail formation. Poor reduction of the bone translates directly into irregularities of the nailbed.

The proximal nail should be reinserted into the nail fold. The replaced nail keeps the nail fold open for new nail growth and provides a protective cover for the nailbed and a precise template for new nail to follow as it regenerates. It also serves as a rigid splint for any underlying fractures and reduces postoperative discomfort and improves postoperative function. Some evidence suggests though that replacing the nail may be unnecessary [30] and may delay wound healing and increase the risk of infection in children. [31]

Before replacement, a small hole should be made in the nail, preferably so that it is not overlying the laceration. This is to allow drainage and thus prevent a growing hematoma to separate the nail from the nailbed.

The nail is then placed back in the nail fold as a stent and held in position by 5-0 or smaller nylon sutures placed by one or a combination of the techniques below:

  • Distally through the hyponychium and the nail.

  • Through the nail and proximal to the nail fold. [33]

  • Through a half-buried horizontal mattress suture placed down proximal to the nail fold into proximal nail then back out the nail fold.

  • Through the paronychia and nail bilaterally.

  • As a dorsal figure-of-eight suture [34] - A suture is placed transversely just distal to the hyponychium, then placed proximal to the nail fold in the same direction and tied back to itself. If the nail slips laterally, 2 small vertical cuts may be made in the nail for the suture to catch upon.

  • An alternative figure-of-eight suture [35] - A suture is placed along one paronychium for approximately 5 mm, then taken over the nail and sutured along the opposite paronychium in the same direction as the first suture, such that the sutures cross over the nail.
  • Utilizing a double stitch [35]  - A combination of both-described figure-of-eight sutures, without necessarily having to create a figure-of-eight suture with each stitch. A suture is placed along one paronychium for approximately 5 mm, then taken over the nail and sutured along the opposite paronychium in the opposite direction as the first suture and tied over the nail. A second suture is then placed proximal to the eponychium and taken over the nail plate through the fingertip just distal to the hyponychium and tied off. 

  • In lieu of sutures, tissue adhesives such as Indermil (n- butyl cyanoacrylate) or Dermabond (octyl-2-cyanoacrylate) may be applied along the perionychium after the nail is replaced. [36] Tissue adhesives are also a less invasive option for nailbed and nail repair. [37]

    • In one randomized controlled trial, nailbed laceration repair using Dermabond required less time with no difference in cosmetic or functional outcomes compared to suture repair. [38] The adhesive should be allowed to dry prior to replacing the nail.

    • Nail fragments may be repaired together first using adhesive, then secured into the nail fold by a thin layer placed under the nail, using gentle downward pressure while the adhesive dries. [39]

    • Alternatively, nail fragments may be pieced together on the nailbed, with a light coating of adhesive wiped or dripped between adjoining fragments and on skin adjacent to the perimeter of the nail. As the adhesive dries, use forceps to maintain external pressure. [40]

    • Chloramphenicol ointment may be used in a similar fashion for simple lacerations, with a small amount applied under the nail so that the ointment forms an adhesive layer as it is positioned into the nail fold. [41]

  • If the original nail is missing, nonadherent gauze, aluminum suture package material, 0.020-inch reinforced silicone sheeting, acrylic (artificial) nail [42] , or splints made from hypodermic syringes [43] or nasogastric tubing [44] may be used as the splint in place of the nail.

  • Dress the injured finger with nonadherent gauze and 2-inch gauze roll then splint the finger.

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