Nail bed injury

seminar presentation on nail bed injury.

1. NAIL BED INJURY SEMINAR PRESENTATION Dr Prajwal K Rao

2. 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

3. 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

4. Nail bed Injury 75% males Long fingers commonly involved Common age : 4-30 years Cause – Deforming Force

5. Clinical examination Sensory examination Pattern of nail bed laceration Involvement of germinal and dorsal roof matrix Associated Subtotal Pulp amputation

6. Imaging AP, Lateral and Oblique views of injured fingers.

7. Classification Subungual hematoma Simple lacerations Stellate lacerations Severe Crush Avulsion

8. Trephination Helps to reduce 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

9. Nail bed Lacerations

10. Indications for Nail bed 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

11. Positioning and Exposure Under tourniquet control and Local anesthesia Freer elevator inserted b/w nail plate and nail bed from distal to proximal

12. Elevation of dorsal roof matrix to expose laceration under nail fold or germinal matrix

13. 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

14. If nail is not available! OPTIONS: Artificial Silicone nail Suture Package Remember to make couple of holes in the nail

15. 5 mm of 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.

16. Nail bed graft Loss of 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

17. 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.

18. Germinal Matrix Avulsion

19. 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.

20. Tuft fracture Nail injury in combination with finger tip fracture. Options: Repair of nail bed and placing nail back on the bed. K wire through the medullary cavity.

21. Postoperative Care Non adherent 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.

22. 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.

23. Non adherence (onycholysis) Nail absence Cornified nail bed Nail spikes/cysts

24. Reference

25. Thank you