Imaging Studies

Depending on the extent of injury, radiologic evaluation with anteroposterior, lateral, and oblique views of the injured finger(s) may be useful to rule out foreign bodies and fractures or dislocations of the distal finger.^[6]

In a study of children with nail bed (nailbed) injuries, the authors found that 50% of their patients had an associated distal phalangeal fracture, most often a comminuted tuft fracture.^[16]Most tuft fractures, in the setting of a nail bed injury, require no specific treatment outside of addressing the nail bed injury and protective splinting. Transverse shaft fractures that are significantly displaced may require surgical repair.^[17]

In a study utilizing point-of-care ultrasound in patients presenting to the ED with distal finger trauma, sensitivity was 93.4% and specificity was 100% for diagnosing nail bed injury.^[18]

Treatment & Management

Brown RE. Acute nail bed injuries. Hand Clin. 2002 Nov. 18(4):561-75. [QxMD MEDLINE Link].
Inglefield CJ, D'Arcangelo M, Kolhe PS. Injuries to the nail bed in childhood. J Hand Surg [Br]. 1995 Apr. 20(2):258-61. [QxMD MEDLINE Link].
de Alwis W. Fingertip Injuries. Emerg Med Australas. 2006 Jun. 18(3):229-37. [QxMD MEDLINE Link].
Van Beek AL, Kassan MA, Adson MH, Dale V. Management of acute fingernail injuries. Hand Clin. 1990 Feb. 6(1):23-35; discussion 37-8. [QxMD MEDLINE Link].
Loréa P. Primary care of nail traumas. Chir Main. 2013 Jun. 32 (3):129-35. [QxMD MEDLINE Link].
Tully AS, Trayes KP, Studdiford JS. Evaluation of nail abnormalities. Am Fam Physician. 2012 Apr 15. 85 (8):779-87. [QxMD MEDLINE Link].
Nanninga GL, de Leur K, van den Boom AL, de Vries MR, van Ginhoven TM. Case report of nail bed injury after blunt trauma; what lies beneath the nail?. Int J Surg Case Rep. 2015. 15:133-6. [QxMD MEDLINE Link].
Chang J, Vernadakis AJ, McClellan WT. Fingertip injuries. Clin Occup Environ Med. 2006. 5 (2):413-22, ix. [QxMD MEDLINE Link].
Zook EG. Anatomy and physiology of the perionychium. Hand Clin. 1990 Feb. 6(1):1-7. [QxMD MEDLINE Link].
Zook EG. Understanding the perionychium. J Hand Ther. 2000 Oct-Dec. 13(4):269-75. [QxMD MEDLINE Link].
Haneke E. Anatomy of the nail unit and the nail biopsy. Semin Cutan Med Surg. 2015 Jun. 34 (2):95-100. [QxMD MEDLINE Link].
Baswan S, Kasting GB, Li SK, Wickett R, Adams B, Eurich S, et al. Understanding the formidable nail barrier: A review of the nail microstructure, composition and diseases. Mycoses. 2017 May. 60 (5):284-295. [QxMD MEDLINE Link]. [Full Text].
James V, Heng TYJ, Yap QV, Ganapathy S. Epidemiology and Outcome of Nailbed Injuries Managed in Children's Emergency Department: A 10-Year Single-Center Experience. Pediatr Emerg Care. 2021 Mar 12. [QxMD MEDLINE Link].
Guy RJ. The etiologies and mechanisms of nail bed injuries. Hand Clin. 1990 Feb. 6(1):9-19; discussion 21. [QxMD MEDLINE Link].
Wahba G, Cheung K. Pediatric hand injuries: Practical approach for primary care physicians. Can Fam Physician. 2018 Nov. 64 (11):803-810. [QxMD MEDLINE Link]. [Full Text].
Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg [Am]. 1999 Nov. 24(6):1166-70. [QxMD MEDLINE Link].
Gaston RG, Chadderdon C. Phalangeal fractures: displaced/nondisplaced. Hand Clin. Aug 2012. 28(3):395-401. [QxMD MEDLINE Link].
Gungor F, Akyol KC, Eken C, Kesapli M, Beydilli I, Akcimen M. The value of point-of-care ultrasound for detecting nail bed injury in ED. Am J Emerg Med. 2016 Sep. 34 (9):1850-4. [QxMD MEDLINE Link].
Mignemi ME, Unruh KP, Lee DH. Controversies in the treatment of nail bed injuries. J Hand Surg Am. 2013 Jul. 38 (7):1427-30. [QxMD MEDLINE Link].
Simon RR, Wolgin M. Subungual hematoma: association with occult laceration requiring repair. Am J Emerg Med. Jul 1987. 5(4):302-4. [QxMD MEDLINE Link].
Mignemi ME, Unruh KP, Lee DH. Controversies in the treatment of nail bed injuries. J Hand Surg Am. 2013 Jul. 38 (7):1427-30. [QxMD MEDLINE Link].
Garcia-Rodriguez JA. Draining a subungual hematoma: procedures and assessments video series. Can Fam Physician. 2013 Aug. 59 (8):853. [QxMD MEDLINE Link].
Patel L. Management of simple nail bed lacerations and subungual hematomas in the emergency department. Pediatr Emerg Care. 2014 Oct. 30 (10):742-5; quiz 746-8. [QxMD MEDLINE Link].
Meek S, White M. Subungual haematomas: is simple trephining enough?. J Accid Emerg Med. 1998 Jul. 15(4):269-71. [QxMD MEDLINE Link].
Seaberg DC, Angelos WJ, Paris PM. Treatment of subungual hematomas with nail trephination: a prospective study. Am J Emerg Med. May 1991. 9(3):209-10. [QxMD MEDLINE Link].
Lankford HV. Subungual Hematoma in the Mountains. Wilderness Environ Med. 2016 Mar. 27 (1):164. [QxMD MEDLINE Link].
Tzeng YS. Use of an 18-gauge needle to evacuate subungual hematomas. J Emerg Med. Jan 2013. 44(1):196-7. [QxMD MEDLINE Link].
Kaya TI, Tursen U, Baz K, Ikizoglu G. Extra-Fine Insulin Syringe Needle: An Excellent Instrument for the Evacuation of Subungual Hematoma. Dermatol Surg. 2003 Nov. 29(11):1141-3. [QxMD MEDLINE Link].
Kain N, Koshy O. Evacuation of subungual haematomas using punch biopsy. J Plast Reconstr Aesthet Surg. Nov 2010. 63(11):1932-3. [QxMD MEDLINE Link].
Khan MA, West E, Tyler M. Two millimetre biopsy punch: a painless and practical instrument for evacuation of subungual haematomas in adults and children. J Hand Surg Eur. Sep 2011. 36(7):615-7. [QxMD MEDLINE Link].
Means KR Jr, Saunders RJ. Understanding and Measuring Long-Term Outcomes of Fingertip and Nail Bed Injuries and Treatments. Hand Clin. 2021 Feb. 37 (1):125-153. [QxMD MEDLINE Link].
Chiche L, Jeandel C, Lyps C, et al. Fingertip nail bed injuries in children: Comparison of suture repair versus glue (2-octylcyanoacrylate) with 1-year follow-up. Hand Surg Rehabil. 2020 Dec. 39 (6):550-555. [QxMD MEDLINE Link].
O'Shaughnessy M, McCann J, O'Connor TP, Condon KC. Nail re-growth in fingertip injuries. Ir Med J. December 1990. 83:136-7. [QxMD MEDLINE Link].
Miranda BH, Vokshi I, Milroy CJ. Pediatric nailbed repair study: nail replacement increases morbidity. Plast Reconstr Surg. April 2012. 129:1028. [QxMD MEDLINE Link].
Greig A, Gardiner MD, Sierakowski A, Zweifel CJ, Pinder RM, Furniss D, et al. Randomized feasibility trial of replacing or discarding the nail plate after nail-bed repair in children. Br J Surg. 2017 Nov. 104 (12):1634-1639. [QxMD MEDLINE Link]. [Full Text].
Harrison BP, Hilliard MW. Emergency department evaluation and treatment of hand injuries. Emerg Med Clin North Am. 1999 Nov. 17(4):793-822. [QxMD MEDLINE Link].
Jeys LM, Khafagy R. A useful technique for securing nails: the figure-of-eight suture. Br J Plast Surg. 2001 Oct. 54(7):651. [QxMD MEDLINE Link].
Shaw A, Findlay J, Kulkarni M. Management of fingertip and nail bed injuries. Br J Hosp Med (Lond). 2011 Aug. 72 (8):M114-8. [QxMD MEDLINE Link].
Hallock GG. Expanded applications for octyl-2-cyanoacrylate as a tissue adhesive. Ann Plast Surg. 2001 Feb. 46(2):185-9. [QxMD MEDLINE Link].
Edwards S, Parkinson L. Is Fixing Pediatric Nail Bed Injuries With Medical Adhesives as Effective as Suturing?: A Review of the Literature. Pediatr Emerg Care. 2016 Dec 12. [QxMD MEDLINE Link].
Strauss EJ, Weil WM, Jordan C, Paksima N. A Prospective, Randomized Controlled Trial of 2-Octylcyanoacrylate Versus Suture Repair for Nail Bed Injuries. J Hand Surg [Am]. Feb 2008. 33(2):250-3. [QxMD MEDLINE Link].
Richards AM, Crick A, Cole RP. A novel method of securing the nail following nail bed repair. Plast Reconstr Surg. 1999 Jun. 103(7):1983-5. [QxMD MEDLINE Link].
Hallock GG, Lutz DA. Octyl-2-Cyanoacrylate adhesive for rapid nail plate restoration. J Hand Surg [Am]. 2000 Sep. 25(5):979-81. [QxMD MEDLINE Link].
Pasapula C, Strick M. The use of chloramphenicol ointment as an adhesive for replacement of the nailplate after simple nail bed repairs. J Hand Surg [Br]. 2004 Dec. 29(6):634-5. [QxMD MEDLINE Link].
Purcell EM, Hussain M, McCann J. Fashionable splint for nailbed lacerations: the acrylic nail. Plast Reconstr Surg. 2003 Jul. 112(1):337-8. [QxMD MEDLINE Link].
Etoz A, Kahraman A, Ozgenel Y. Nail bed secured with a syringe splint. Plast Reconstr Surg. 2004 Nov. 114(6):1682-3. [QxMD MEDLINE Link].
Bayraktar A, Ozcan M. A nasogastric catheter splint for a nailbed. Ann Plast Surg. 2006 Jul. 57(1):120. [QxMD MEDLINE Link].
Yang J, Wang T, Yu C, Gu Y, Jia X. Reconstruction of large area defect of the nail bed by cross finger fascial flap combined with split-thickness toe nail bed graft: A new surgical method. Medicine (Baltimore). 2017 Feb. 96 (6):e6048. [QxMD MEDLINE Link].
Renzoni A, Pirrera A, Lepri A, Cammarata P, Molinaro R, Dalla Vedova A. Medical tattooing, the new frontiers: a case of nail bed treatment. Ann Ist Super Sanita. 2017 Oct-Dec. 53 (4):334-336. [QxMD MEDLINE Link]. [Full Text].
Sun Y, Azad S. The occasional nail bed laceration. Can J Rural Med. 2020 Apr-Jun. 25 (2):79-81. [QxMD MEDLINE Link].

Media Gallery

Trephination of a subungual hematoma.
Nailbed repair.

of 2

Author

Darrell Sutijono, MD Attending Physician, Department of Emergency Medicine, Kaiser Permanente Santa Clara Medical Center

Darrell Sutijono, MD is a member of the following medical societies: American College of Emergency Physicians, American Institute of Ultrasound in Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Mark A Silverberg, MD, MMB, FACEP Assistant Professor, Associate Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate Medical Center

Mark A Silverberg, MD, MMB, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Residency Directors in Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Eric M Kardon, MD, FACEP Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center

Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Medical Association of Georgia

Disclosure: Nothing to disclose.

Acknowledgements

Tom Scaletta, MD President, Smart-ER (http://smart-er.net); Chair, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine

Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.