Procedure: Nail bed repair

Procedure, instructions and discussion

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.

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Instructions

Indications

• NAIL BED LACERATION – with or without nail plate avulsion
• SUBUNGUAL HAEMATOMA > 50% OF NAIL SURFACE

Contraindications (ABSOLUTE/relative)

• Extensive nail bed injury with underlying fracture (refer to hand surgery)
• Infection or contamination (requires treatment first and delayed closure)

Alternatives

• Referral to hand surgery (e.g. complex fracture-dislocation, nail bed avulsion with germinal matrix loss)
• Conservative management (e.g. subungual hematoma drainage without nail removal)
• Wound dressing only for superficial nail edge injuries
• Delayed repair in heavily contaminated wounds (after irrigation and short interval)

Informed consent

VERBAL – IF HAS CAPACITY

• Simple procedure with a low risk of complications

Consent via person responsible if patient does not have capacity

Potential complications

• Pain
• Failure to prevent deformity (ridging, splitting, adhesion to nail bed)
• Nail loss or delayed regrowth
• Infection
• Missed germinal matrix injury

Infection control

• Standard precautions
• Clean (not sterile) field
• Sterile gloves and instruments
• Irrigation with normal saline

Area

• Minor procedures room or resuscitation bay
• Good lighting essential

Staff

• Procedural clinician
• Assistant (if needed for retraction or patient comfort)

Equipment

• Sterile gauze and drapes
• Syringe and 25G needle (local anaesthetic)
• Nail elevator or blunt probe
• Fine scissors
• Forceps
• 6-0 or 7-0 absorbable sutures
• Tissue adhesive (optional)
• Nail bed splint (original nail, synthetic nail, syringe tubing tube to size)
• Dressing (non-adherent gauze, light bandage)

Positioning

• Patient seated or supine with hand comfortably supported
• Digit extended and immobilized
• Use tourniquet (glove finger roll) if needed to reduce bleeding

Medication

• Digital nerve block: 1–2 ml lignocaine 1% (no adrenaline) per side
• Consider oral analgesia for post-procedure comfort
• Tetanus prophylaxis if indicated

Sequence (Preparation)

• Explain procedure and obtain verbal consent
• Perform digital nerve block
• Clean and drape digit
• Assess nail plate and surrounding tissue
• Irrigate wound thoroughly with saline
• Remove nail plate carefully if needed to visualize nail bed

Sequence (Repair)

• Explore nail bed for full extent of laceration
• Use magnification and good lighting if possible
• Align and suture nail bed with 6-0 or 7-0 absorbable sutures
• Avoid tension; approximate edges carefully
• Replace nail plate or use synthetic splint under nail fold to prevent adhesion
• Secure nail plate/splint with tissue adhesive or single suture if needed
• Apply non-adherent dressing and compressive bandage

Sequence (Difficulty identifying injury)

• Elevate nail carefully from proximal fold to improve visualization
• Use sterile saline to gently separate tissue planes
• If blood obscures view, irrigate repeatedly or reassess under tourniquet

Post-procedure care

WOUND CARE

• Keep dressing dry for 48 hours, then daily gentle cleaning
• Splint remains until nail regrowth (2 weeks if synthetic splint, longer if native nail)

FOLLOW-UP

• Review in 7–10 days
• Monitor for signs of infection or impaired healing

DOCUMENTATION

• Mechanism, extent of injury, procedure performed
• Block type, nail plate removed/replaced
• Fracture if present, any antibiotics or tetanus given

Tips

• Replace the native nail plate to prevent scarring of the nail matrix
• Use absorbable sutures to avoid need for removal
• Splint the nail fold to preserve nail contour
• Suture with minimal tension, tissue is delicate
• Consider prophylactic antibiotics for open fractures or gross contamination

Discussion

Nail bed lacerations are common hand injuries often resulting from blunt or crush trauma, frequently associated with subungual haematomas or distal phalanx fractures. Accurate and prompt repair is crucial to preserve cosmetic appearance and functional regrowth of the nail.

A digital block without adrenaline is the anaesthetic technique of choice, providing excellent pain relief. The nail plate often needs to be removed to fully visualize the injury. If it is intact, it may be cleaned and replaced as a natural splint to prevent synechiae between the nail bed and the proximal nail fold.

Meticulous technique is required in approximating the delicate tissue of the nail bed. Even minor misalignment can lead to long-term deformity such as nail ridging, splitting, or non-adherence. Absorbable sutures (6-0 or finer) are standard, and tissue adhesive may be considered in partial lacerations.

In the presence of a distal phalanx fracture, nail bed lacerations are considered open fractures, and some practitioners recommend prophylactic antibiotics—though evidence is mixed.

Reinsertion of the nail or a synthetic splint is a critical step in maintaining normal nail anatomy. Without this, the eponychial fold may adhere to the healing nail bed, causing deformity.

Patients should be followed up for assessment of healing, pain control, and detection of complications. Nail regrowth typically takes 6–12 weeks depending on patient age and injury severity.

References

• Zook EG, Guy RJ, Russell RC. A study of nail bed injuries: causes, treatment, and prognosis. J Hand Surg Am. 1984 Mar;9(2):247-52.
• Bharathi RR, Bajantri B. Nail bed injuries and deformities of nail. Indian J Plast Surg. 2011 May;44(2):197-202
• Maitra S, Bhattacharjee S, Baidya DK. Nail bed injuries and their management. Indian J Plast Surg. 2011;44(2):219–225.
• Bhaskar AR, Srinivasan R. The Role of Nail Replacement in the Repair of Nail Bed Injuries in Children. J Bone Joint Surg Br. 2006;88(10):1345–1348.
• Miranda BH, Milner RH. A prospective study of nail bed injuries: predicting the need for surgery. J Plast Reconstr Aesthet Surg. 2010;63(3):409–413.
• Leddy JP, Panagos A. Nail bed injuries and deformities. Clin Plast Surg. 2013;40(3):407–412.

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