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NAIL BED INJURY

LONG-TERM OUTCOMES
Can be viewed on www.diuchirurgiemain.org

Christian Dumontier, MD, PhD
with the Help of Dr Sylvie Carmès, MD

BSSH Instructional
courses - series 7
MY TALKS
• Nail Bed injury Trauma

• Hook Nail Sequelae

• Pincer nail (Acquired) dystrophy

• Split nail
Sequelae
• Other post-traumatic sequelae
MY TALKS

• Hook Nail
• Nail unit anatomy
• Pincer nail
• Nail Bed injury • Split nail and other
post-traumatic
dystrophies
B A S I C N A I L A N AT O M Y A N D
PHYSIOLOGY
THE NAIL UNIT
Is a distinct organ whose anatomy and
physiology are different from the finger skin

Phylogenetically the most primitive appendage
is the claw, found in all terrestrial tetrapods

Nails are characteristic primate appendages
found on at least some digits of all species

Evolution of nails was closely associated with
the use of hands (and feet) as manipulatory
organs.
APPARITION OF NAILS IS
ASSOCIATED WITH

Lengthening of the phalanges
(so the digits could be flexed
against the palm)

Splaying out of tile terminal
phalanges to accommodate
the tactile sensory pads

Spearman RIC. Phylogeny of the nail. Journal of Human Evolution(1985) 14, 57-61
WHAT IS THE ANATOMY
OF THE NAIL UNIT ?
A BONY SUPPORT
AND ITS ADJACENT LIGAMENTOUS
STRUCTURES

A proximal fibrous nucleus with the mixing of fibers
from the extensor, the flexor, the collateral ligament

Of which arose the Flint’s ligament (lateral
attachement of the nail apparatus)
Appareil extenseur

Ligament inter-osseux

latéral de Flint

Ligament hyponichial
THE NAIL PLATE

The peryonychium:

All the tissues located under the nail place

The paronychium:

All the tissues located over the nail plate
THE PERYONYCHIUM

Nail matrix (germinal)

Nail bed (sterile)

Hyponychium
THE NAIL MATRIX

Starts proximal, 1,4 mm +/- 0,6 mm
from the insertion of the extensor
tendon

Extends up to the lunula (not always
visible)

Also cover the proximal part of the
nail plate
THE NAIL MATRIX

Only structure able to produce the nail
plate +++

Cannot be replace by another tissue +++

It thickens the nail plate by adding new
cellular layers
THE NAIL BED

Highly specialized structure responsible:

For the adhesion of the nail plate

Longitudinal ridges mixing with the
underlying surface of the nail plate

For the nail plate shape

May sometimes, in acute cases, be
replace by another tissue
THE HYPONYCHIUM

The distal part of the nail bed where
the nail plate looses its adherence +++

Its loss (distal amputations; pulp flaps) is
responsible for a painful nail plate adhesion

Mechanical barrier + immunologic
function (rich in polynuclear cells)
THE PARONYCHIUM

Proximal nail wall/fold

Lateral nail walls/folds
PROXIMAL NAIL FOLD

Cutaneous structure that encircles the
nail plate

The cuticle is the seal that closes the
nail fold

It is responsible for the shape of the
nail plate
LATERAL NAIL FOLDS

Encircle the nail plate

Are responsible for both
its shape and orientation
THE NAIL PLATE

Supple structure made of three layers of
keratynocytes

0,5 mm of thickness, made of 20% of water,

Double convexity (longitudinal and
transverse) ➤ esthetic and functional
harmony

Its shape depends from the integrity of the
underlying structures and paronychium
CLINICAL CONSEQUENCES

• The nail plate is so supple that it is often intact in nail
trauma

• It has to be removed to see and repair the lesions +++
NAIL PLATE SHAPE
DEPENDS OF

The bony support

The volume of the pulp

The nail bed

The nail folds
CLINICAL CONSEQUENCES

• You cannot have a normal nail over an abnormal bone
• Bone loss = hook-nail
• Large phalanx = racket nails
• Malunion = ungueal dystrophia
• Arthrosis = pincer nail…
CLINICAL CONSEQUENCE

Nail plate adhesion is
only possible if the nail
bed is intact ➙
anatomical surgical
reconstruction
PHYSIOLOGY

Normal nail growth is of 1,9 to 4,4 mm/month, a
mean of 0,3 mm/jour
Two months for the nail plate to exit from the proximal fold,
and 6 months for a complete nail regrowth (fingers)

As the first nail is always irregular, clinical results
cannot be judged before one year
PHYSIOLOGY
Factors that increase nail Factors that decrease nail
growth growth

Long fingers > 20 years

After nail plate avulsion During night

Pregnancy In immobilized patients,
denutrition
Onychophagia
After an infection
In warm countries

Those factors cannot be modified by the surgeon
AFTER A TRAUMA

Nail plate growth stops for 3 weeks,
proximal part thickens

Then nail growth speeds up for 50 days
(the plate becomes thinner)

Then it slows for 30 days

Which led to the constitution of a Beau’s
line which moves with the nail
VASCULARIZATION
A. superficielle

A. distale

A. proximale

A. collatérale palmaire

The nail unit is highly vascularized and healing is
usually not a problem

The same applies for venous or lymphatic drainage
INNERVATION

Very rich

Usually nerves follow the vessels

Nail surgery is very painful +++
NAIL UNIT FUNCTIONS

Useful to scratch or to defend ourselves
Thermal exchanges
Mechanical protection for the dorsum of the
finger
Esthetic +++
Functional +++: it increases pulp sensibility
by a counter pressure effect as it is the only
rigid structure of the fingertip
Picasso kept a long little fingernail for mixing paints,
Turkish men commonly keep such a nail for opening
cigarette wrappers.
A MORE COMPLEX SYMBOLISM

In the movie «doubt», father Flynn keeps his nails long and
clean. This is a metaphor that you can do what ever you want
if you don't get caught. You have to do it "clean". This
references to the child molestation.

Later in the movie, Meryl Streep's character tells him to cut his
nails. She symbolically tells him to stop molesting the children.

The fingernails cover the fingers just as the Mercy Seat covered the Ark of the
Covenant (arche d’alliance). 
N A I L B E D I N J U RY
EPIDEMIOLOGY OF NAIL
TRAUMA

Epidemiological study (187 cases in 2 years) - About
8% of all hand emergencies

Associated lesions

Pulp: 26,7%

Distal phalanx Fx: 15,5%

Pulp lesion + Fx: 26,2%

Another lesion on the finger/hand: 11,8%

Almost 70% of associated lesions !
EPIDEMIOLOGY OF NAIL TRAUMA

Crushing mechanism +++

50% of lesions were in the distal part of the nail unit

At least 65% needed a surgical repair
ONE CLINICAL
CONSEQUENCE

Do not forget X-rays !
H O W T O R E PA I R I T ?
WHAT DO WE NEED ?
A good anesthesia / pain killers

Small instruments

A freer elevator

Loupes

Small sutures (PDS 6/0, non-colored)

A new nail to cover your repair

No antibiotics (even if fractured)
Metcalfe D, Aquilina AL, Hedley HM. Prophylactic antibiotics in open distal phalanx fractures: systematic review and meta-
analysis. J. Hand Surg Eur 2016, Vol. 41E(4) 423–430
ALTHOUGH
CONTROVERSIAL
Every time it is possible replace
the nail plate. It allows:

To « mold » the repair

To protect it

To limit pain during dressing

To increase pulp sensibility

But don’t forget to make a hole
for drainage
SUBUNGUAL HEMATOMAS
No spontaneous evacuation as the edges of the
nail are still adherent
Nail hematoma develops in the less adherent area
(i.e.the lunula)
Very painful, can be pulsatil
If the surface of the hematoma > 25% you may
discuss
Simple drainage: Needle nail trephination or
with a paper clip. Always two holes at the level
of the lunula.
Nail plate removal ➜ to verify nail bed
integrity and to repair it if necessary.
NO CLEAR
RECOMMANDATION
Prospective studies have
shown:

That only 50% of nail bed
injuries are reparable

There was no difference
between repair and
simple drainage

I prefer simple drainage

Simon, 1987; Seaberg, 1991
Subungual Foreign Bodies

- The simplest (w/o anesthesia): progressive thinning of
the nail plate with a knife. You remove chips of nail plate
until you can take the foreign body, but it is ruining for
the nail plate !

- Better to remove the plate !

- Be careful with wood splinters: may putrify
NAIL BED INJURY
Remove the nail plate (re-fix it
or replace it at the end)

Wash injured tissues

No debridement

Reduce and eventually fix a
fracture

Repair the nail bed (6/0
sutures)

One can expect > 90% good
results for simple lesions
IN MORE SEVERE CASES

Principles are identical

No debridement, non
vascularized parts will
act like grafts
After nail plate
removal and lavage
Initial lesion

After nail plate substitute
After suture of pulp
and nail bed
IF THERE IS AN ASSOCIATED
FRACTURE ?

Nail plate refixation is
usually all that is
needed to stabilize the
fracture

You can also use
needles or K-Wires
IN CASE OF NAIL BED LOSS ?

If the nail bed is still
attached to the nail plate,

Replace the plate back in
place (the nail bed is use
like a tensioned graft)
IN CASE OF NAIL BED LOSS ?

Or detach it and use it as
a graft
IF THERE IS A NAIL BED
LOSS ➡ NAIL BED GRAFT

Split thickness nail bed
graft (same finger,
hallux)

Take less than 300 µ
thickness which is
difficult due to the
convexity of the hallux
nail bed (thickness 900µ)
3 months FU
FULL-THICKNESS NAIL
BED GRAFT

Can also be used if the
fragment is available or
if there is a non-
replantable finger

14 months FU
DISTAL FINGERTIP
AMPUTATION

Most amputations go
through the bed with
preservation of the matrix

50% of lesions are in the
distal half of nail apparatus
➤ Replantation when
possible is the best treatment
IF REPLANTATION NOT
POSSIBLE
Reposition (10% complete
and 34% partial graft survival
rate in children - cutting
point is 4 years) - [Butler]

61% success rate if done
within 4 hours vs 0% after
[Moiemen]

Still worth trying in children

Butler DP et al. The outcomes of digital tip amputation replacement as a composite graft in a paediatric population. J Hand Surg
Eur 2016;41(2):164-170
Moiemen NS, Elliot D. Composite graft replacement of digital tips. J Hand Surg Br 1997; 22B(3):346-352
IF REPLANTATION NOT POSSIBLE
☞REPOSITION-FLAP

Reposition « en bloc » of
the nail apparatus and
phalanx

And coverage with a volar
flap

Good survival of the nail,
but deformity (hook-nail)
in 50-60% of cases due to
bone resorption
THE DESEPIDERMIZED
FLAP
For distal nail bed injury
involving the pulp (up
to 75% of the nail bed)

Reconstruct the pulp
with a volar flap

Which distal part is
desepidermized and
used as a dermal graft
for the nail bed
Dumontier C et al. Ann Chir Plast Esthet 1992; 37(5):553-559
NOT TO FORGET

Simple dressing in less
severe lesion that will
leave the patient with a
limited dystrophy

Or tissues
approximation
Oguro said we do not need to repair
the nail bed

6 Months

Coverage of the lesions by an artificail nail
plate to allow for nail bed regeneration /
healing

6W 9M
External fixation of the injured nail
bed with the INRO Surgical Nail
Splint. J.Hand Surg 1989: 236-41
IN CHILDREN ?
Surgical exploration is also
needed
Good results (85%) were
observed after surgical
repair compare to 52% in
non-repaired injuries
(Ardouin)
Beware of Seymour’s lesion
that needs k-wire fixation
AFTER lavage
MATRIX INJURIES

Principles are the same but sequelae
are always more severe: ridges,
cracks, or even nail loss

To extend the incisions: use Kanavel’s
technique: 2 incisions at the junction
proximal-lateral fold

Extend to the DIP if necessary

The scar of the nail plate will be
hidden under the lateral folds.
INJURIES TO THE
PARONYCHIUM

Better to use flaps to
reconstruct the folds
Many thanks to Dr Lindsay MUIR
and the BSSH for your invitation

Thanks for your
attention