Procedure: Nail bed repair

The Procedure

Hello again from the Emergency Procedures team,

Nail bed laceration repair

Today we’re taking a closer look at nail bed lacerations — a deceptively simple injury that can lead to permanent nail deformity if not managed carefully. As always, we’ve reviewed the evidence and translated it into practical bedside guidance.

Detailed written instructions and explanation are available here and in our Free App (iOS and Android). This video is hot off the press and we want your help improving it. Drop us a line with any suggestions

So, without further ado…here is the video

The rationale…

What are the indications for repairing a nail bed?

Nail bed lacerations, or subungual haematoma involving more than 50% of the nail surface — which likely indicate an underlying nail bed laceration. Both should be treated as potential nail bed injuries requiring nail plate removal and direct inspection.

How do I visualise and repair the injury?

Start with a digital nerve block using lignocaine 1% (no adrenaline). Remove the nail plate if it obstructs the view. Irrigate with saline, identify the full extent of the laceration, and repair using 6-0 or 7-0 absorbable sutures under good lighting and, if available, magnification.

Which injuries do I need to refer to a hand surgeon?

Refer any injury with an underlying complex fracture-dislocation, extensive nail bed loss, or avulsion involving the germinal matrix. These cases often require microsurgical repair to restore nail growth and alignment. Also refer if the wound is heavily contaminated, devitalised, or delayed in presentation, as these are harder to manage successfully in the ED.

What are the main complications?

Pain, infection, delayed nail growth, and permanent nail deformity — such as ridging, splitting, or non-adherence. These are often preventable with careful inspection, precise suture placement, and proper splinting.

Are there special considerations for open fractures or contamination?

Yes. Nail bed lacerations with an associated distal phalanx fracture are considered open fractures. Many clinicians recommend prophylactic antibiotics. In cases of gross contamination, delay closure until after irrigation and reassessment.

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