Nail avulsion

Background

A. Nail plate; B. lunula; C. root; D. sinus; E. matrix; F. nail bed; G. hyponychium; H. free margin.

• Can be complete or partial
• Result from blunt trauma

Clinical Features

• Nail completely or partial removed from nailbed
• May present with concomitant nailbed laceration

Differential Diagnosis

Hand and finger injuries

• Distal finger
  • Finger amputation
  • Fingertip laceration
  • Nail avulsion
  • Nailbed laceration
  • Subungual hematoma
• Other finger/thumb
  • Boutonniere deformity
  • Mallet finger
    • Swan neck deformity
  • Jammed finger
  • Jersey finger
  • Trigger finger
  • Ring avulsion injury
  • De Quervain tenosynovitis
  • Infiltrative tenosynovitis
  • Metacarpophalangeal ulnar ligament rupture (Gamekeeper's thumb)
• Hand
  • Dupuytren contracture
• Wrist
  • Drummer's wrist
  • Ganglion cyst
  • Lunotriquetral ligament instability
  • Scaphoid fracture
  • Extensor digitorum tenosynovitis
  • Compressive neuropathy ("bracelet syndrome")
  • Intersection syndrome
  • Snapping Extensor Carpi Ulnaris
  • Vaughn Jackson syndrome
• General
  • Hand and finger dislocations
  • Hand and finger fractures
  • Hand and finger infections
  • Gout and pseudogout
  • Hand and finger tendon injuries
  • High-pressure injection injury
  • Osteoarthritis
  • Rheumatoid arthritis
  • Ring removal

Diagnosis

• Obtain hand xray to check for fracture, dislocation, and foreign body
• Detailed neurovascular exam of hand noting sensation and capillary refill

Management

• For partial avulsion, gently lift nail but do not remove to inspect nail bed for laceration
• For complete avulsion:
  • Repair any nailbed laceration
  • Replace nail into nailfold after cleaning nail and suture into place
  • If no nail, place a non-adherent, petroleum containing gauze into nailfold.

Disposition

• Keep nail splint or gauze in place for 2-3 weeks
• Re-eval wound in 3-5 days and if gauze was placed in nailfold replace with new gauze