Nail avulsion

Background

• Generally results from blunt trauma

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

Clinical Features

Full nail avulsion. The lunula and nail bed are exposed. The lunula is pinkish-white in color with a smooth surface. The nail bed is bright red in color with longitudinal dermal ridges stretching from the lunula to the distal groove.

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

Differential Diagnosis

Distal Finger (Including Nail) Injury

• Distal interphalangeal dislocation (finger)
• Distal phalanx (finger) fracture
• Finger amputation
• Fingertip avulsion
• Finger infection
• Nailbed laceration
• Nail avulsion
• Subungual hematoma

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

Evaluation

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

Management

(a) Fingernail avulsion; (b) polypropylene nail substitute; (c) clinical result at 12 months.

• 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 nail fold. Can Also use aluminum wrapping of suture package as pseudo-nail to allow appropriate spacing for new nail to grow in. This should be left in place for 2-3 weeks.
  • Wound should be re-evaluated in 3-5 days and gauze replaced

Disposition

• Discharge