MANUAL MINORS
Nail bed lacerations are injuries affecting the tissue beneath the nail (nail bed) and may be accompanied by damage to the nail, proximal fold, and surrounding structures. These injuries are often caused by direct trauma, such as crushes, deep cuts, or entrapments.
Due to the sensitivity and protective function of the nail bed, these lacerations can affect the appearance and function of the finger, in addition to causing intense pain and a high risk of infection.
Diagnosis
The diagnosis of a nail bed laceration is based on clinical evaluation after trauma, observing for bleeding beneath the nail (subungual haematoma), nail deformity or tear, and exposure of the nail bed.
The depth of the laceration must be assessed, as some injuries may affect the nail matrix (responsible for nail growth), potentially compromising nail regeneration in the long term.
In cases of significant trauma, X-rays are necessary to rule out fractures of the distal phalanx, which frequently accompany these lacerations.
Differential Diagnosis
Condition | Main Clinical Characteristics | Key Differentiation |
|---|---|---|
Subungual haematoma | Blood accumulation beneath the nail, no visible laceration | Intense pain, no visible cut in the nail bed |
Nail avulsion | Nail detached partially or completely | Partial or complete detachment of the nail |
Distal phalanx fracture | Intense pain, deformity, and possible nail bed laceration | Radiographic confirmation of fracture |
Acute paronychia | Inflammation and pain in the nail fold | Localised infection, no history of trauma |
Traumatic onycholysis | Nail detachment without underlying laceration | Nail separated from the bed, no visible cut |
Emergency Management
Initial management of a nail bed laceration involves careful cleaning of the wound with sterile saline solution to prevent infection. If the nail is partially detached or damaged, it can be gently removed to allow proper evaluation and treatment of the nail bed.
In cases of large subungual haematomas, trephination (drainage) may be performed to relieve pressure and pain. Open wounds should be covered with sterile dressings, and antibiotic prophylaxis is recommended if there is a high risk of infection.
If the laceration is deep and affects the nail matrix, surgical repair under local anaesthesia is required. In some cases, the nail itself can be used as a temporary “splint” to protect the nail bed while it heals. It is also essential to assess the need for a tetanus vaccination update, especially in contaminated wounds.
Definitive Treatment
Definitive treatment may include surgical repair of the nail bed using fine absorbable sutures. If the nail has been completely detached, in many cases, a new nail is allowed to grow, which may take several months. In cases where the nail matrix has been severely damaged, permanent deformities in nail growth may occur.
Complete recovery involves adequate protection of the finger during healing and avoiding additional trauma. Physiotherapy is not typically required, but regular follow-up is important to ensure proper nail regrowth and detect potential complications such as infections or onychodystrophy.
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