I Say, Leave the Darn Thing Alone

The teaching about nailbed injuries is that if you have a crush injury or any sort of injury involving the proximal matrix of the nail it has to be removed, the matrix, or nailbed, repaired, and the nail replaced to keep the matrix open for the new nail. The worry is subungual hematomas.

A pregnant lady came in who had cut her nail and fingertip with a breadknife. She was on lovenox because it was a high-risk pregnancy. She had a linear laceration through her nail but it was three quarters of the way towards the tip. My staff indicated we should explore the nail bed and pry the nail up to see if there was damage underneath it.

I did that; her finger was numb, so I pryed up the end of the nail and it started bleeding like crazy. Surprise, surprise. Before, there was no visible hematoma, no bleeding from the nail. But the nailbed is so friable in a normal person, let alone someone anticoagulated, that it's a mess to reveal. This lady did have a laceration; I had to trim off maybe 3-4 millimeters of her nail to get to it, and then we repaired it with absorbable sutures.

But, before we started messing with it, it was FINE. According to Tintanelli, nailbed repair is required for open fracture underneath, disruption of the proximal matrix, and subungual hematoma. Some recent lectures on EM podcasts have disputed the subungual hematoma thing; the others I buy. Otherwise, I say LEAVE THE NAILBED ALONE. It bleeds, I don't think it helps proximally. Thoughts?

Oh--to take the nail off, gently dissect along the bed from the front with drivers, grip and pull away from the matrix along the axis of the finger, then repair, then suture the nail back in place through the nail itself with simple or matress sutures.