Nail bed closure

Nail Bed Closure

The approach to nail bed repair depends on the extent of the injury, the type of wound present, and any associated pathology.

Small subungual hematomas that involve less than 25% of the nail bed can be managed with observation or trephination if the area is painful. For hematomas covering more than 25% of the nail bed, it is recommended to remove the nail plate so the nail bed can be examined and any lacerations repaired. Simple or stellate (star-shaped) nail bed lacerations can be treated with suture repair or with 2-octylcyanoacrylate (Dermabond).

Materials Needed for Nail Bed Repair

The following materials are typically required for this procedure:

1. 1% lidocaine without epinephrine, for a digital nerve block
2. 10 mL syringe
3. 25- or 27-gauge needle for the digital nerve block
4. 0.5-inch or 1-inch Penrose drain, to be used as a finger tourniquet
5. Povidone-iodine solution
6. Emesis basin
7. Sterile drapes
8. Laceration tray (includes instruments like iris scissors, a small needle driver, forceps, and a small elevator)
9. 6-0 resorbable monofilament suture
10. 6-0 nylon suture (save the foil packaging to use as an interposition stent under the eponychial fold if the patient’s nail is unavailable or unusable)
11. 2-octylcyanoacrylate (Dermabond), if this method is chosen
12. Non-adherent Xeroform dressing
13. Sterile dressings (gauze and Kling wrap)
14. Finger splint
15. Loupe magnification (optional)

Nail Bed Repair Technique

Suture Repair and 2-Octylcyanoacrylate Repair

The patient lies supine with the affected hand palm-down on an arm extension or a small Mayo stand. The injured finger is irrigated generously with saline to remove debris from the nail area. It is then prepped with povidone-iodine solution, and the area is draped with a sterile extremity towel.

A digital nerve block is performed, making sure all four digital nerves supplying the injured finger are covered. A Penrose drain is then applied as a finger tourniquet, wrapping from distal to proximal and securing it at the base of the finger. The nail plate is then removed, and the type of nail bed laceration is assessed.

Nail Plate Removal

• Using iris scissors placed between the nail bed and the nail plate (hyponychium), systematically free the nail plate by opening and closing the scissor tips to separate the tissue.
• Advance the scissors proximally until reaching the nail fold. Be sure to free the nail plate proximally, radially, and ulnarly.
• Once the nail plate has been removed from the underlying nail bed, keep it for later placement under the eponychial fold (place it in an emesis basin soaked with povidone-iodine).

Suture Repair

• Irrigate the nail bed and remove any hematoma and debris before beginning the repair.
• Classify the laceration as either simple or stellate.
• Clean the wound edges and use iris scissors to trim any irregularities, ensuring a smooth, tension-free repair.
• Using a small tissue elevator, gently undermine the edges of the nail bed laceration from the underlying periosteum to mobilize the tissue for repair.
• Repair the laceration with simple interrupted 6-0 resorbable monofilament sutures.

2-Octylcyanoacrylate Repair

• After irrigating, cleaning, and prepping the wound, apply a single layer of 2-octylcyanoacrylate to the injury site.
• While the tissue adhesive dries (about 60–90 seconds), manually approximate the wound edges.
• Once the first layer has dried, apply a second layer and allow it to dry completely.

Eponychial Interposition

• After repairing the nail bed laceration, you can use either the removed nail plate or a piece of suture packaging foil as a stent under the eponychial fold. This maintains space for new nail growth and helps prevent adhesions and future nail plate deformities.
• The edge of the removed nail plate can be trimmed and shaped so it fits easily under the eponychial fold.
• Either interposition option can be secured in place with 6-0 nylon suture or leftover 2-octylcyanoacrylate.
• If using 6-0 nylon suture to hold the nail plate in place: The first pass is made antegrade through the skin of the dorsum of the finger, about 5 mm proximal to the nail fold. The needle exits between the eponychial fold and the nail bed. The next pass goes through the prepared nail plate from back to front, followed by another pass through the nail plate from front to back. The final pass is made retrograde, starting between the eponychial fold and the nail bed and exiting through the dorsal skin about 5 mm proximal to the nail fold. Tension on the suture pulls the nail plate into position under the eponychial fold. The suture is then tied, creating a horizontal mattress configuration.

Dressings and Aftercare

• Apply a non-adherent Xeroform gauze over the repaired nail bed.
• Wrap the finger with a Kling bandage.
• Protect the repaired nail bed with a finger splint to immobilize the DIP joint.
• Patients are discharged with a 5-day course of oral antibiotics for infection prophylaxis (e.g., cephalexin 250 mg p.o. four times daily).
• The repair site should be re-evaluated in 5 to 7 days.
• The interposed nail or suture foil can be removed from under the eponychial fold three weeks after treatment.
• Advise the patient that new nail growth may take three to six months and that cosmetic deformities are common after nail bed repair.

References

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