NAIL BED INJURY

LONG-TERM OUTCOMES
Can be viewed on www.diuchirurgiemain.org

Christian Dumontier, MD, PhD

with the Help of Dr Sylvie Carms, MD

BSSH Instructional
courses - series 7
 MY TALKS
Nail Bed injury Trauma

Hook Nail Sequelae

Pincer nail (Acquired) dystrophy

Split nail
Sequelae
Other post-traumatic sequelae
 MY TALKS

Hook Nail
Nail unit anatomy
Pincer nail
Nail Bed injury Split nail and other
post-traumatic
dystrophies
B A S I C N A I L A N AT O M Y A N D
PHYSIOLOGY
 THE NAIL UNIT
Is a distinct organ whose anatomy and
physiology are different from the finger skin

Phylogenetically the most primitive appendage

is the claw, found in all terrestrial tetrapods

Nails are characteristic primate appendages

found on at least some digits of all species

Evolution of nails was closely associated with

the use of hands (and feet) as manipulatory
organs.
APPARITION OF NAILS IS
ASSOCIATED WITH

Lengthening of the phalanges

(so the digits could be flexed
against the palm)

Splaying out of tile terminal

phalanges to accommodate
the tactile sensory pads

Spearman RIC. Phylogeny of the nail. Journal of Human Evolution(1985) 14, 57-61
WHAT IS THE ANATOMY
OF THE NAIL UNIT ?
A BONY SUPPORT
 AND ITS ADJACENT LIGAMENTOUS
STRUCTURES

A proximal fibrous nucleus with the mixing of fibers

from the extensor, the flexor, the collateral ligament

Of which arose the Flints ligament (lateral

attachement of the nail apparatus)
Appareil extenseur

Ligament inter-osseux

latral de Flint

Ligament hyponichial
 THE NAIL PLATE

The peryonychium:

All the tissues located under the nail place

The paronychium:

All the tissues located over the nail plate

 THE PERYONYCHIUM

Nail matrix (germinal)

Nail bed (sterile)

Hyponychium
 THE NAIL MATRIX

Starts proximal, 1,4 mm +/- 0,6 mm

from the insertion of the extensor
tendon

Extends up to the lunula (not always

visible)

Also cover the proximal part of the

nail plate
 THE NAIL MATRIX

Only structure able to produce the nail

plate +++

Cannot be replace by another tissue +++

It thickens the nail plate by adding new

cellular layers
 THE NAIL BED

Highly specialized structure responsible:

For the adhesion of the nail plate

Longitudinal ridges mixing with the

underlying surface of the nail plate

For the nail plate shape

May sometimes, in acute cases, be

replace by another tissue
 THE HYPONYCHIUM

The distal part of the nail bed where

the nail plate looses its adherence +++

Its loss (distal amputations; pulp flaps) is

responsible for a painful nail plate adhesion

Mechanical barrier + immunologic

function (rich in polynuclear cells)
 THE PARONYCHIUM

Proximal nail wall/fold

Lateral nail walls/folds

 PROXIMAL NAIL FOLD

Cutaneous structure that encircles the

nail plate

The cuticle is the seal that closes the

nail fold

It is responsible for the shape of the

nail plate
 LATERAL NAIL FOLDS

Encircle the nail plate

Are responsible for both

its shape and orientation
 THE NAIL PLATE

Supple structure made of three layers of

keratynocytes

0,5 mm of thickness, made of 20% of water,

Double convexity (longitudinal and

transverse) esthetic and functional
harmony

Its shape depends from the integrity of the

underlying structures and paronychium
 CLINICAL CONSEQUENCES

The nail plate is so supple that it is often intact in nail

trauma

It has to be removed to see and repair the lesions +++

 NAIL PLATE SHAPE
DEPENDS OF

The bony support

The volume of the pulp

The nail bed

The nail folds

 CLINICAL CONSEQUENCES

You cannot have a normal nail over an abnormal bone

Bone loss = hook-nail
Large phalanx = racket nails
Malunion = ungueal dystrophia
Arthrosis = pincer nail
CLINICAL CONSEQUENCE

Nail plate adhesion is

only possible if the nail
bed is intact
anatomical surgical
reconstruction
 PHYSIOLOGY

Normal nail growth is of 1,9 to 4,4 mm/month, a

mean of 0,3 mm/jour
Two months for the nail plate to exit from the proximal fold,
and 6 months for a complete nail regrowth (fingers)

As the first nail is always irregular, clinical results

cannot be judged before one year
 PHYSIOLOGY
Factors that increase nail Factors that decrease nail
growth growth

Long fingers > 20 years

After nail plate avulsion During night

Pregnancy In immobilized patients,

denutrition
Onychophagia
After an infection
In warm countries

Those factors cannot be modified by the surgeon

 AFTER A TRAUMA

Nail plate growth stops for 3 weeks,

proximal part thickens

Then nail growth speeds up for 50 days

(the plate becomes thinner)

Then it slows for 30 days

Which led to the constitution of a Beaus

line which moves with the nail
 VASCULARIZATION
A. superficielle

A. distale

A. proximale

A. collatrale palmaire

The nail unit is highly vascularized and healing is

usually not a problem

The same applies for venous or lymphatic drainage

 INNERVATION

Very rich

Usually nerves follow the vessels

Nail surgery is very painful +++

NAIL UNIT FUNCTIONS

Useful to scratch or to defend ourselves

Thermal exchanges
Mechanical protection for the dorsum of the
finger
Esthetic +++
Functional +++: it increases pulp sensibility
by a counter pressure effect as it is the only
rigid structure of the fingertip
Picasso kept a long little fingernail for mixing paints,
Turkish men commonly keep such a nail for opening
cigarette wrappers.
 A MORE COMPLEX SYMBOLISM

In the movie doubt, father Flynn keeps his nails long and
clean. This is a metaphor that you can do what ever you want
if you don't get caught. You have to do it "clean". This
references to the child molestation.

Later in the movie, Meryl Streep's character tells him to cut his
nails. She symbolically tells him to stop molesting the children.

The fingernails cover the fingers just as the Mercy Seat covered the Ark of the
Covenant (arche dalliance).
N A I L B E D I N J U RY
 EPIDEMIOLOGY OF NAIL
TRAUMA

Epidemiological study (187 cases in 2 years) - About

8% of all hand emergencies

Associated lesions

Pulp: 26,7%

Distal phalanx Fx: 15,5%

Pulp lesion + Fx: 26,2%

Another lesion on the finger/hand: 11,8%

Almost 70% of associated lesions !

EPIDEMIOLOGY OF NAIL TRAUMA

Crushing mechanism +++

50% of lesions were in the distal part of the nail unit

At least 65% needed a surgical repair

 ONE CLINICAL
CONSEQUENCE

Do not forget X-rays !

H O W T O R E PA I R I T ?
 WHAT DO WE NEED ?
A good anesthesia / pain killers

Small instruments

A freer elevator

Loupes

Small sutures (PDS 6/0, non-colored)

A new nail to cover your repair

No antibiotics (even if fractured)

Metcalfe D, Aquilina AL, Hedley HM. Prophylactic antibiotics in open distal phalanx fractures: systematic review and meta-
analysis. J. Hand Surg Eur 2016, Vol. 41E(4) 423430
 ALTHOUGH
CONTROVERSIAL
Every time it is possible replace
the nail plate. It allows:

To mold the repair

To protect it

To limit pain during dressing

To increase pulp sensibility

But dont forget to make a hole

for drainage
SUBUNGUAL HEMATOMAS
No spontaneous evacuation as the edges of the
nail are still adherent
Nail hematoma develops in the less adherent area
(i.e.the lunula)
Very painful, can be pulsatil
If the surface of the hematoma > 25% you may
discuss
Simple drainage: Needle nail trephination or
with a paper clip. Always two holes at the level
of the lunula.
Nail plate removal to verify nail bed
integrity and to repair it if necessary.
 NO CLEAR
RECOMMANDATION
Prospective studies have
shown:

That only 50% of nail bed

injuries are reparable

There was no difference

between repair and
simple drainage

I prefer simple drainage

Simon, 1987; Seaberg, 1991

 Subungual Foreign Bodies

- The simplest (w/o anesthesia): progressive thinning of

the nail plate with a knife. You remove chips of nail plate
until you can take the foreign body, but it is ruining for
the nail plate !

- Better to remove the plate !

- Be careful with wood splinters: may putrify

 NAIL BED INJURY
Remove the nail plate (re-fix it
or replace it at the end)

Wash injured tissues

No debridement

Reduce and eventually fix a

fracture

Repair the nail bed (6/0

sutures)

One can expect > 90% good

results for simple lesions
IN MORE SEVERE CASES

Principles are identical

No debridement, non
vascularized parts will
act like grafts
 After nail plate
removal and lavage
Initial lesion

After nail plate substitute

After suture of pulp
and nail bed
 IF THERE IS AN ASSOCIATED
FRACTURE ?

Nail plate refixation is

usually all that is
needed to stabilize the
fracture

You can also use

needles or K-Wires
IN CASE OF NAIL BED LOSS ?

If the nail bed is still

attached to the nail plate,

Replace the plate back in

place (the nail bed is use
like a tensioned graft)
IN CASE OF NAIL BED LOSS ?

Or detach it and use it as

a graft
IF THERE IS A NAIL BED
LOSS NAIL BED GRAFT

Split thickness nail bed

graft (same finger,
hallux)

Take less than 300

thickness which is
difficult due to the
convexity of the hallux
nail bed (thickness 900)
3 months FU
 FULL-THICKNESS NAIL
BED GRAFT

Can also be used if the

fragment is available or
if there is a non-
replantable finger

14 months FU
 DISTAL FINGERTIP
AMPUTATION

Most amputations go
through the bed with
preservation of the matrix

50% of lesions are in the

distal half of nail apparatus
Replantation when
possible is the best treatment
 IF REPLANTATION NOT
POSSIBLE
Reposition (10% complete
and 34% partial graft survival
rate in children - cutting
point is 4 years) - [Butler]

61% success rate if done

within 4 hours vs 0% after
[Moiemen]

Still worth trying in children

Butler DP et al. The outcomes of digital tip amputation replacement as a composite graft in a paediatric population. J Hand Surg
Eur 2016;41(2):164-170
Moiemen NS, Elliot D. Composite graft replacement of digital tips. J Hand Surg Br 1997; 22B(3):346-352
IF REPLANTATION NOT POSSIBLE
REPOSITION-FLAP

Reposition en bloc of
the nail apparatus and
phalanx

And coverage with a volar

flap

Good survival of the nail,

but deformity (hook-nail)
in 50-60% of cases due to
bone resorption
 THE DESEPIDERMIZED
FLAP
For distal nail bed injury
involving the pulp (up
to 75% of the nail bed)

Reconstruct the pulp

with a volar flap

Which distal part is

desepidermized and
used as a dermal graft
for the nail bed
Dumontier C et al. Ann Chir Plast Esthet 1992; 37(5):553-559
 NOT TO FORGET

Simple dressing in less

severe lesion that will
leave the patient with a
limited dystrophy

Or tissues
approximation
Oguro said we do not need to repair
the nail bed

6 Months

Coverage of the lesions by an artificail nail

plate to allow for nail bed regeneration /
healing

6W 9M
External fixation of the injured nail
bed with the INRO Surgical Nail
Splint. J.Hand Surg 1989: 236-41
 IN CHILDREN ?
Surgical exploration is also
needed
Good results (85%) were
observed after surgical
repair compare to 52% in
non-repaired injuries
(Ardouin)
Beware of Seymours lesion
that needs k-wire fixation
AFTER lavage
 MATRIX INJURIES

Principles are the same but sequelae

are always more severe: ridges,
cracks, or even nail loss

To extend the incisions: use Kanavels

technique: 2 incisions at the junction
proximal-lateral fold

Extend to the DIP if necessary

The scar of the nail plate will be

hidden under the lateral folds.
 INJURIES TO THE
PARONYCHIUM

Better to use flaps to

reconstruct the folds
Many thanks to Dr Lindsay MUIR
and the BSSH for your invitation

Thanks for your

attention