MANUAL MINORS
The presence of foreign bodies under the nail (also known as “subungual foreign body”) is a common injury that occurs when fragments of materials such as splinters, glass, or metal become lodged beneath the nail, typically as a result of trauma or accidents.
These foreign bodies can cause pain, inflammation, infection, and in some cases, impair normal nail growth if not properly removed. Due to the limited space beneath the nail, careful management is necessary to avoid further damage to the nail bed and matrix.
Diagnosis
Diagnosis is based on the trauma history and the patient’s symptoms, such as intense pain, redness, swelling, and in some cases, drainage of purulent material or bleeding. Clinically, the foreign body may be visible beneath the nail, or changes in the nail’s colour or shape may be noted, such as a subungual haematoma. Tenderness to touch and palpation along the nail is also common.
If the foreign body is not visible, or if it is suspected to have penetrated more deeply into the nail bed, X-rays can be used to identify metallic fragments or other radiopaque objects. In more complex cases, an ultrasound or CT scan may be necessary to locate the foreign body if it is not visible upon direct inspection.
Differential Diagnosis
Condition | Main Clinical Characteristics | Key Differentiation |
|---|---|---|
Subungual haematoma | Blood accumulation beneath the nail, no foreign body | Intense pain, purple or black colour under the nail |
Onycholysis | Nail detachment due to trauma | Nail separated from the bed without a visible foreign body |
Subungual infection (paronychia) | Redness, swelling, and pain around the nail | History of infection or inflammation without trauma |
Traumatic nail bed injury | Damage to the nail bed without the presence of a foreign object | No object trapped under the nail |
Emergency Management
The management of subungual foreign bodies begins with evaluating the type and location of the object. If it is superficial and visible, careful removal can be attempted using a sterile instrument, such as fine tweezers or a scalpel, after administering local anaesthesia to control pain. If the nail is damaged or the foreign body is deeply embedded, partial or total nail avulsion may be required to provide full access and allow for proper removal.
It is important to clean the wound with sterile saline solution to reduce the risk of infection and administer antibiotic prophylaxis if there are signs of infection or if the injury is contaminated. In some cases, such as with organic splinters, all fragments must be removed to prevent abscess formation.
Definitive Treatment
Definitive treatment depends on the depth and size of the foreign body. In simple cases, removal under local anaesthesia is sufficient, followed by protecting the nail or nail bed with a sterile dressing. In more severe cases, with significant damage to the nail bed or matrix, surgical reconstruction of the affected tissues may be required.
Recovery involves keeping the area clean and dry to prevent infection and follow-up to ensure normal nail growth if a partial or total avulsion occurred. Signs of infection should be monitored in the days following the removal, and antibiotic treatment should be adjusted as needed.
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