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Chirurgie de la main 32 (2013) 129135

Review

Primary care of nail traumas


Longle traumatique. Prise en charge initiale
P. Lora
SOS Main Strasbourg centre, 4, rue Ste-Elisabeth, 67000 Strasbourg, France
Received 22 October 2011; received in revised form 6 January 2013; accepted 4 February 2013
Available online 25 April 2013

Abstract
Injuries to the nail complex are common in adults and children. These complex injuries often involve the paraungueal tissues, fingertip and
bone. Specialized primary care is essential to limiting the sequelea that are typically difficult to repair secondarily. The current state of knowledge
on nail bed lacerations and defects is reviewed and compared to our own experience. Special attention is paid to nail restoration in distal amputation
cases and we propose an original technique to restore nail length.
# 2013 Elsevier Masson SAS. All rights reserved.
Keywords: Nail lacerations; Nail bed injuries; Nail; Distal amputation; Fingertip injury; Flap; Eponychial resection

Rsum
Les traumatismes de lappareil ungual sont frquents, tant chez ladulte que chez lenfant. Ces traumatismes sont complexes, intressant
parfois les tissus priunguaux, la pulpe et los. Une prise en charge initiale spcialise est indispensable pour limiter les squelles, qui sont
difficiles corriger. Une mise au point confrontant les donnes de la littrature notre exprience est propose. Les donnes actuelles de prise en
charge des plaies unguales et pertes de substance sont dtailles, avec une attention particulire donne la restauration de lappareil ungual lors
des amputations distales. Nous proposons dans ce cadre une nouvelle technique originale de restauration de la longueur de longle.
# 2013 Elsevier Masson SAS. Tous droits rservs.
Mots cls : Plaie de longle ; Lit de longle ; Plaie de la matrice ; Amputation distale ; ponychium ; Lambeau homodigital ; Rsection ponychiale

1. Introduction
The nail has a major esthetic role, both for men and women.
Beyond esthetics, the nails functional role cannot be ignored. It
affects fingertip stability and contributes to the precision of
two-finger grasping.
Appropriate care in an emergency context is essential
because the results of secondary surgery are clearly less
predictable than when surgery is performed as a first-line
treatment.
Since nail trauma can have multiple causes, the type of
injury varies: crush, subungeal hematoma, simple laceration,
contusion (with or without associated fracture), defect in the

sterile and/or germinal matrix, total or subtotal distal


amputation, injuries to the perionychium tissues, etc.
In most cases, surgery is performed on an outpatient basis
under local or regional anesthesia. In children, even young
ones, general anesthesia is very rarely indicated for these types
of injuries in our practice. Our experienced team works under
good conditions with local anesthesia supplemented by
equimolar mixture of nitrous oxide/oxygen (EMNO) sedation.
Use of surgical loupes and a tourniquet cuff is essential in all
cases to ensure a high-quality repair. After an unforeseen event
at our center, luckily not serious, we no longer use a finger
tourniquet. There is always a risk of forgetting it, with
potentially disastrous consequences [1]. The assessment
consists of strict A/P and lateral X-rays in cases of crush
injury or contusion (saw, wood shaper, etc.) since 50% of all
nail injuries have an associated fracture [2].

E-mail address: loreapatrick@yahoo.fr.


1297-3203/$ see front matter # 2013 Elsevier Masson SAS. All rights reserved.
http://dx.doi.org/10.1016/j.main.2013.02.021

130

P. Lora / Chirurgie de la main 32 (2013) 129135

Fig. 1. Anatomical drawing of the nail complex. 1. Extensor tendon insertion.


2. Proximal fold. 3. Lunula. 4. Nail plate. 5. Hyponychium. 6. Sterile matrix. 7.
Germinal matrix.

2. Anatomy
The nail complex consists of the nail plate, nail bed,
paronychium (lateral folds), eponychium and hyponychium
[3,4] (Fig. 1).
The nail bed is divided into two histologically different
portions: the germinal matrix and the sterile matrix. The germinal
matrix extends from the origin of the nail bed (at 1.4 mm from the
distal insertion of the extensor tendon, on average) to the lunula.
It seems responsible for 90% of nail formation, although this is
widely debated [5,6]. The nail plate is a keratinized structure,
initially formed under the eponychium by addition of cells
derived from the germinal matrix. The sterile matrix extends
from the lunula to the hyponychium. Its main role is to provide
nail adhesion. Furthermore, it marginally adds to the thickness of
the nail plate. The hyponychium is located at the junction
between the sterile matrix and the fingertip. It marks the junction
between the free end of the nail and the adherent part of the nail
plate. Along with acting as a mechanical barrier, the hyponychium acts as an immune barrier since it contains large amounts
of lymphocytes and polymorphonuclear leukocytes. The
paronychium is formed by the lateral folds and lateral nail
junction. It has a similar role to the hyponychium. The
eponychium covers the proximal part of the nail and the
germinal matrix. It ends as a thin epithelial layer that adheres to
the nail plate (cuticle), which also acts as a barrier. The
eponychium usually participates in nail plate formation by
making it shiny, but this may not necessarily be true given our
observations after eponychium resection.
The vascularization of the nail complex comes from the
terminal branches of the proper palmar digital arteries, with a
contribution from the dorsal ramifications coming from the
middle phalanx [7,8]. The dorsal anastomotic arches were
described by Flint [8]. They provide the nail complex with very
abundant vascularization and give the surgeon more freedom
when dissecting various flaps.
3. Subungeal hematoma
Because of the abundant vascularization of the nail bed, any
crush injury may result in an extensive hematoma. The pressure

generated by this hematoma can be significant and lead to


intense pain. Nail trephination is required to drain the
hematoma, relieve pain and also avoid a secondary infection.
If the hematoma is small and not painful, it can be left as it is
[9]. Multiple techniques have been described for trephining the
nail. We prefer performing a large window with a No 15 scalpel
blade. In practice, it is essential to make sure the opening is
large enough to not block itself up again.
Until recently, the line of thought was to explore the nail bed
if the hematoma covered more than 25% of the nail area [10].
This was recently questioned as a result of randomized studies
showing that trephination is sufficient, no matter the size of the
hematoma, as long as the paraungueal tissues and nail plate are
intact [11,12]. A prospective study demonstrated that only
hematomas beyond 50% associated with a fracture were
susceptible to produce injuries to the nail bed that required
repair [13]. Similarly to Dumontier et al. [9], we only explore
the nail bed in cases of complicated hematomas, namely
hematomas associated with paraungueal injuries, nail plate
injuries or a fracture [14].
4. Wounds and lacerations of the nail bed
In cases of nail bed wounds, meticulous suturing must be
performed to prevent nail separation or detachment. This is
even more important if the injury is located in the germinal
matrix. To ensure that enough of the nail bed is exposed to carry
out good quality suturing, the plate must be detached using a
thin spatula or the end of blunt scissors, while making sure not
to damage the matrix. If the wound is contused, fine
debridement is preferable; the defect will be filled by dissecting
tissue from the matrix or the bed and the periosteum. When the
injury is proximal, the germinal matrix will be approached
through counterincisions at the junction between the proximal
and lateral folds [15]. We use transparent 6/0 PDTTM on a
triangular needle to suture the nail bed. If the plate is good, it
will be repositioned under the proximal fold after trephination.
We no longer attach the plate because we want to avoid
technical complications associated with paronychium or
eponychium suturing. Similarly to Dumontier et al. who
attache the plate with Steri-StripsTM [9], we found that the plate
quickly adheres to nail bed and will stay in place if the dressing
is changed carefully. If the plate cannot be repositioned, we are
satisfied with sliding a piece of Tulle Gras under the
eponychium to prevent synechia, which could lead to
pterygium in the future. Replacing the nail plate or putting
in a substitute does not seem to affect the result [16].
5. Associated bone injuries
Appropriate treatment of any associated fracture is essential.
If the ungual tuberosity (apical tuft) is fractured, no treatment is
needed other than repair of the nail injury itself. With more
proximal fractures, the fracture must be reduced anatomically
and any free-floating fragments or dorsal bone spicules must be
excised to avoid secondary nail deformation. If the fracture is
displaced or unstable, internal fixation is usually performed

P. Lora / Chirurgie de la main 32 (2013) 129135

with a 0.8 or 1.0 mm longitudinal K-wire, left in place for


4 weeks. If possible, distal interphalangeal arthrorisis should be
avoided, but in certain cases of very proximal fractures, it is
unavoidable. We do not perform internal fixation on all
fractures; if the fracture is stable, an intact nail plate can provide
sufficient stabilization.
In cases of dorsal transverse subtotal amputation, with
fracture of the nail bed and the distal phalanx, we prefer
performing a Foucher nail fixation [17]. This consists of
simultaneously performing internal bone fixation and nail
fixation by inserting a 20 gauge diameter needle through the
nail on both sides of the injury. If better compression is
required, a stainless steel suture can be tightened between the
two ends. We currently use PDSTM instead of steel for this
purpose. A longitudinal K-wire may be required to maintain
reduction during the procedure; in certain cases, it can be left in
place during healing. The indications for this type of nail
fixation have now been extended to nail plate fractures without
a bone fracture [18].
6. Bone injuries in children
Hastings and Simmons noted that 47% of open hand
fractures in children were located at the distal phalanx [19]. The
most common injury mechanism was the finger being crushed
in a door [20].
Children often present with a dislocation of the proximal
part of the nail plate that can be hard to see. This injury, called a
Seymour fracture (Fig. 2A), must be identified and properly
treated, despite its benign appearance [21]. Lateral X-rays
could show asymmetry in the epiphysis, or could sometimes be
normal despite the epiphyseal detachment found during
exploration. The fracture site is rinsed out and reduced. If

Fig. 2. A. Diagram of a Seymour fracture. B. Diagram of a subtotal distal


amputation with a volar bridge.

131

the injury is unstable, we pin this type of fracture with a


hypodermic needle used as an axial K-wire. The nail bed may
be broken or the germinal matrix avulsed at its proximal
insertion. If avulsed, the matrix will be repositioned under the
eponychium using two horizontal mattress sutures. The primary
short-term risk is infection, but there is no consensus as to
appropriate prophylactic antibiotics [20,22]. The parents
should be warned that growth disorders are possible, even
without a secondary infection.
The second type of crush injury found in children is subtotal
dorsal amputation with an ungual tuberosity fracture and partial
soft tissue degloving of the distal phalanx [23,24]. The distal
fragment is pedicled by a cutaneous soft tissue bridge and the
blood vessels are usually intact (Fig. 2B). After lavage of the
fracture site, the reduction is maintained by an axial
hypodermic needle and the nail bed is sutured or reinserted.
This injury can be impressive, but in most cases the repair
provides excellent results.
In cases of total distal amputation, we have the same
indications as the one described in detail for adults later on in
this review. Unlike some reports [25], we have found that solely
repositioning a composite, non-vascularized fragment does not
lead to good results; necrosis, contraction and bone resorption
occur too often [23,26].
7. Nail bed defects
Fortunately, distal defects are more common than defects of
the germinal matrix, which is better protected by its proximal
location and the presence of the eponychium.
Skin grafts (regular or inverted placement) have mostly been
abandoned because of inconsistent results [2729]. Because of
the sequelae induced at the donor site, the full-thickness grafts
introduced by McCash [30] are now also obsolete. Splitthickness nail bed grafts are said to be effective for
reconstructing sterile matrix defects [31,32]. If the defect is
small, the graft can be harvested from the intact areas of the nail
bed of the injured finger. If the defect is more extensive, the
graft is taken from one toe. In some cases, the matrix has
adhered to the avulsed plate. It must be located and inspected so
that the matrix tissue can be repositioned and act as an
autograft. The matrix does not have to be detached from the
plate before using it as a graft [10]. Split-thickness matrix grafts
can be directly placed on the bone if the bone is still
vascularized [4,31]. Some of the published results with this
graft have been disappointing and there is evidence of an
appreciable amount of donor site morbidity (25% of cases)
[33,34].
Although these split-thickness nail bed grafts are the gold
standard, some authors have challenged this concept, hesitating
to make the initial injury worse by inflicting another one
[35]. Very good results have been reported (7090% of normal
size) without a graft in cases of defects in up to 90% of the
sterile matrix [36]. The germinal matrix must be preserved
since it is said to be the source of the nail bed regeneration.
Ogunro and Ogunro recommend healing by second-intention,
even in cases of nearly complete avulsion of the sterile matrix

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P. Lora / Chirurgie de la main 32 (2013) 129135

Fig. 3. A. Triangular punch defect of the nail bed and the distal phalanx. B. Nail bed flap for translation with distal-lateral pedicle, closing wedge osteotomy to fill the
triangular bone defect, resection of a triangular piece of the eponychium to restore the length. C. Results after 4 months.

or of cortex exposure; 10 of their 12 cases had more than


6 months of follow-up and all had satisfactory results [35]. We
no longer use nail bed grafts (except bank finger or available
fragment) and up to now, we are satisfied with the results
obtained through second-intention healing.
Use of nail bed flaps is indicated in certain cases [7,37,38].
Because of the abundant vascularization of the nail bed,
longitudinal flaps with a narrow pedicle, attached proximally or
distally, can be dissected. These flaps can be cut to size and
translated or rotated to fill small central defects such as punch
defects (Fig. 3).
Defects of the germinal matrix are tricky to treat. Repair of
the germinal matrix with non-vascularized grafts seems to
provide good, but inconsistent results [5,32,33]. We believe it is
pointless, and even harmful, to mutilate a toe for this purpose. If
the germinal matrix is available but cannot be reimplanted, or a
bank finger is available, attempts can be made to reposition
so it acts as a graft. Only the vascularized transfer of a nail
matrix leads to reproducible results, but the complexity of the
surgery and the sequelae at the donor site limit this indication to
very specific cases [39,40]. A full thickness skin graft
implanted into the nail plate as an esthetic unit provides
satisfactory results and should be considered as an option [41].

This technique has been derived from the eponychial flap


described by Bakhach et al. [42,43]. About 40% of the nail plate
(range: 28.580%) lies under the eponychial fold [44]. By
performing a crescent-shaped resection of the eponychial fold,
while leaving the free end for healing by second-intention, this
portion becomes visible and considerably extends the visible
part of the nail (Fig. 4). We reviewed 14 consecutive cases in
13 patients having an average age of 37 years (range: 1570)
[42]. The eponychial resection was combined with an Elliot
bipedicled advancement flap in five cases, an Atasoy V-Y flap
in eight cases and a Venkataswami V-Y advancement flap in one
case. Patients were reviewed after an average follow-up of
13 months (range: 618). The reconstructed nail length was
87% of the contralateral nail on average (range: 55105%). The
average patient satisfaction score was 9/10 (range: 710).
A hook-nail deformity is a common complication of distal
defects and is difficult to treat secondarily. It has been shown in
cadaver studies that the entire nail bed lays on the distal phalanx
[44]. For the reconstruction to be anatomical, the nail bed must

8. Distal amputations
A composite defect (bone, fingertip and nail bed) exists in
cases of distal amputation. Only non-reimplantable injuries will
be addressed here. The treatment differs depending on if the
patient has a dorsal plane or a volar plane amputation.
8.1. Dorsal or transverse plane amputation
During dorsal or transverse plane amputations, the defect is
mainly in the nail bed and bone. The standard treatment
consists of combining a fingertip flap and a thin split-thickness
nail bed graft. If more than half the nail bed is intact, we do not
use the nail bed flap, but instead remove a crescent-shaped
eponychium piece to lengthen the visible part of the nail [42].

Fig. 4. A. Resection of a crescent-shaped piece of eponychium. B. Results after


14 months.

P. Lora / Chirurgie de la main 32 (2013) 129135

133

Fig. 5. A. Diagram of the combination of a volar advancement flap with a crescent-shaped eponychial resection. B. Distal thumb amputation. Drawing of the
resection. C. Immediate postoperative view. D. Results after 16 months.

not extend beyond the tip of the distal phalanx. To avoid hook
formation, the author proposed removing the excess part of the
nail bed that extends beyond the bone as needed. The technique
is very similar to the distal flap fixation method proposed by
Dumontier et al. [9]. The work performed by Foucher et al.
supports this concept: when the bone is not injured, no hooknail deformity was observed after second-intention healing in
77 patients [45]. In the same vein, Dumontier et al. found a
correlation between the extent of the bone defect and a hooknail deformity [46]. In our practice, we combine an equivalent
crescent-shaped eponychial resection with distal nail bed
resection [47] to restore correct anatomical nail length.
8.2. Volar plane amputation
During the volar plane amputation, the nail bed is preserved
but has lost its bone support. We described an emergency nail
recession to preserve the nail complex [48]. This consists of
using the flap described by Dufourmentel for treating a hooknail deformity in an emergency room setting. At the cost of
moderate bone shortening, the nail complex is preserved and
placed on a good quality bone support, which prevents the
appearance of a hook-nail.
We do not advocate repositioning the bone and nail
complex unit and covering it with a pulp advancement flap, as
proposed by Foucher et al. [45]. It has been shown that bone
resorption almost always occurs, with an average shortening of
4.4 mm, along with persistent hook-nail deformity [49].
Use of a crescent-shaped eponychial resection or nail
recession in the emergency room had led us to establish new
indications for the treatment of non-reimplantable, distal
composite defects at the cost of moderate bone shortening. In
our eyes, preservation of the finger length must not be a dogma.
We prefer reconstructing a finger that is a few millimeters
shorter than having a normal length finger with a dystrophic or
hook nail. As long as the digital cascade is normal, a slight
shortening will not be obvious.

When more than half the nail length is preserved, we


propose covering the bone end by advancing a volar flap and
restoring a visually appealing nail length through a crescentshaped eponychial resection (Fig. 5). When the germinal
matrix is preserved but less than 50% of the nail length is
present, eponychial resection is insufficient to provide
satisfactory nail length. In this case, we use the amputated
nail bed as a graft, in combination with a volar flap [50]. If bone
support is insufficient, we propose adding a part of the
amputated nail bed to act as a repositioned graft; when
combined with nail recession, the entire graft can be placed on
the distal phalanx (instead of on the flap). This seems to be the
best compromise to preserve the nail and limit the hook-nail
deformity (Fig. 6).
9. Injuries to the paraungueal tissues
Wounds or defects in the paronychium must not be
neglected. A deep injury to the eponychium (proximal fold)
can mask an injury to the matrix tissue, which will lead to
pterygium if not repaired.
In cases of a proximal fold defect, various small localized
flaps can be used [51]. Most of the flaps have been described for
treating secondary injuries or burns, and can also be performed
in an emergency room setting.
If the proximal fold is injured, we prefer using the Smith flap
[52], which can be cut into an esthetic unit and used to
successfully reconstruct the fold (Fig. 7). The flap donor site is
not grafted, but left to heal by second-intention. The resulting
appearance is better, since the scar consists of a horizontal line
instead of a triangular graft.
The lateral folds can be reconstructed with a fingertip flap that
will be detached from the distal phalanx and translated laterally.
This flap was initially described for the reconstruction of ingrown
nails [51]. In cases of associated fingertip defect, the flap used for
the reconstruction will be attached so that it juts out laterally, to
allow for simultaneous lateral fold reconstruction. The most

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P. Lora / Chirurgie de la main 32 (2013) 129135

Fig. 6. A. Distal amputation of more than 50% of the nail length. B. Nail recession flap of the intact portion. C. Graft of the amputated nail bed onto the P3 portion
exposed by the recession; fixation using the Foucher technique. D. Results after 4 months.

Fig. 7. A. Injury to the eponychium. Smith flap. Donor site left to heal by
second-intention. B. Results after 2 months. The donor site is barely visible.

difficult part is reconstructing the curve at the junction between


the lateral and proximal folds.
10. Conclusion
Nail traumas must be treated by a specialized team, despite
the benign appearance of these lesions. A comprehensive
approach that takes into account the associated paraungueal and
bone injuries is essential. In cases of nail bed defect, the
techniques described here will typically avoid the need for nail
bed grafts and provide highly satisfactory results in most cases.
Disclosure of interest
The authors declare that they have no conflicts of interest
concerning this article.
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