Nail Bed Anatomy and

Fingertip Injuries
Tamara Rozental, MD

1st Edition author: Craig S. Williams, MD

 • Definitions
• Perionychium: nail bed and surrounding
soft tissue.
• Hyponychium: junction of nail bed and
skin at the distal finger tip.
• Eponychium (cuticle): thin membrane
extending from nail wall to dorsal nail
plate.
• Paronychium: extends along lateral
edges of the nail.

Fingertip injuries
 • Anatomy
• Nail bed: composed of germinal and
sterile matrix.
• Nail fold: composed of ventral floor and
dorsal roof.
• Germinal matrix
• From nail fold to lunula
• Generates 90% of the nail plate
• Sterile matrix
• From lunula to hyponychium
• Provides adherence to nail plate
• Provides 10% of naik thickness

Fingertip injuries
 Anatomy Nail fold (ventral/dorsal)
Eponychium
Hyponichium Nail plate Extensor tendon

Nail bed

Distal phalanx

Flexor tendon

Fingertip injuries
 • Physiology
• Blood supply: from terminal branches of
the volar digital artery.
• Nerve supply: from dorsal branch of
digital nerve.
• Growth rate: ~ 0.1 mm per day.
• Growth slows rate after fourth decade.
• Fingernails grow x 4 faster than toenails.
• After injury, growth is delayed three to
four weeks.

Fingertip injuries
 • Epidemiology of Injuries
• Long finger most common
• Simple lacerations are most
common
• 50% of nail bed injuries are
associated with distal phalangeal
fractures

Fingertip injuries
 • Acute Injuries
Subungal Hematoma
• Disruption of nail bed with intact
nail plate.
• Pain from bleeding into non-
compliant compartment.
• Can evacuate if involves 25-50%
of surface or with severe pain.
• Procedure: drill hole with heated
paper-clip or remove nail.

Fingertip injuries
 • Acute Injuries
Simple Lacerations
• Hematoma >50% of surface area is
typically associated with nail bed
laceration.
• Lacerations should be repaired within 7
days.
• Use digital block with finger tourniquet

Fingertip injuries
Nail bed repair with absorbable suture
May replace the nail as biologic dressing or
substitute with foil or gauze
 • Stellate Lacerations
• Treated in similar fashion.
• Remove any pieces of nail matrix
adherent to underside of nail
plate and replace as graft.
• May require simple or horizontal
mattress sutures.

Fingertip injuries
• Distal phalanx fractures
• Highest predictive value for
nail bed laceration.
• Non-displaced: repair as for
simple laceration.
• Displaced: reduce and
consider K-wires if unstable.
• Complications
• Non-adherence
• Most common post-traumatic
deformity
• Caused by scarring of sterile
matrix
• Distal non-adherence is
typically not problematic
• Proximal non-adherence
causes loose painful nails
• Treatment: scar resection
and bed closure +/- sterile
matrix graft from other
finger or toe
 • Complications
• Hook nail
• Due to loss of bone support
after fingertip amputation
• Prevented by not pulling nail
bed over distal phalanx during
repair
• Treatment: add support to nail
bed (bone grafts, toe transfers)
or reconstruct soft tissue at
fingertip (V-Y advancement,
cross-finger flap, etc)

Fingertip injuries
 • Complications
• Nail ridging
• Caused by scar under nail bed
• Treatment: scar excision and smoothing of
irregularity
• Split nail
• Caused by longitudinal scar in germinal or
sterile matrix
• Typically too wide for excision alone
• Treatment for sterile matrix: excision with
split thickness skin graft (STSG)
• Treatment for germinal matrix: excision with
full thickness skin graft (FTSG)

Fingertip injuries
 • Complications
• Cornified nail bed
• Keratinized material grows from sterile
matrix
• Treatment: removal of remaining matrix and
STSG
• Nail cysts
• From incomplete removal of germinal matrix
• Treatment: removal and complete excision of
germinal matrix

Fingertip injuries
 • Nail Infections
Acute paronychia
• Most common hand infections
• Most common bacteria: gram negative
bacteria and S. aureus
• Early detection
• Warm soaks
• Oral antibiotics
• Late or abscess formation
• Incision and drainage
• May require nail removal
• Oral antibiotics

Fingertip injuries
 • Nail Infections - Chronic Paronychia
• Caused by fungal superinfection
• Treatment
• Oral antifungals
• Topical antifungals
• Marsupialization if unresponsive

Fingertip injuries
 • Fingertip Anatomy
• Distal phalanx
• Conically shaped with distal taper
• Terminates 4 to 5 mm proximal to
fingertip
• Distal tuft : cancellous with thin cortical
rim
• Shaft: diaphyseal bone
• Tendon attachments
• Terminal extensor tendon dorsally
• FDP/FPL broad volar attachment

Fingertip injuries
 • Fingertip Anatomy
• Skin/subcutaneous tissue
• Epidermis
• Flattened cells
• Dermis
• Non-glaborous
• Deep papillary ridges
• Sensory receptors
• Paccinian Corpuscle -> Light Touch
• Meissner Corpuscle -> Fine Touch (moving 2 pt.)
• Merkle Cell -> Discrete Field (static 2 pt.)
• Ruffini End Organ -> Skin Stretch Receptor

Fingertip injuries
 • Fingertip Anatomy
• Fibrous septae
• Extend from dermis to periosteum
• Provide axial/torsional stability to skin at
fingertips
• Form numerous “compartments”
• Nerve/arterial supply
• Dorsal branches to dorsal nail fold/nail organ
• Mid axial branches to lateral nail fold and nail
bed
• Palmar branches to finger pad

Fingertip injuries
 • Injury Patterns
• Loss of small portion of pad
• No loss of nail bed or
hyponychium
• No exposed bone
• Transverse tip amputation
• Loss of part of nail bed and
hyponychium
• Loss of bone
• Loss of part of pad

Fingertip injuries
 • Injury Patterns
• Volar oblique laceration
• Loss of significant portion
of pad
• +/- exposed bone
• No injury to nail bed
• Dorsal oblique laceration
• Significant nail bed injury
• +/- bone injury
• Intact pad

Fingertip injuries
• Treatment Options – Secondary
intention
• Pad injuries ≤1 cm2
• No protruding bone
• Four to six weeks to heal
• Contraction will decrease size of final
defect
• Advantages
• Smaller area of decreased sensation
• Durable when adequate subcutaneous tissue
exists
• Disadvantages
• Can pull sterile matrix volarly and become a
hook nail
 • Treatment Options - Shortening and closure
• May require shortening or ablation of nail bed and
bone
• Nail bed
• If < 50 percent preserved  recommend ablation
• Advantages
• Definitive with short recovery time
• Sensate
• No donor site morbidity
• Disadvantages
• Loss of length
• Shortening of or loss of nail
• Cosmesis

Fingertip injuries
• Treatment Options – Skin graft
• Pad injuries greater than 1 cm2
• Defatted full-thickness skin graft is best
• Donor sites
• Hypothenar skin for smaller grafts
• Non-hair-bearing skin from arm (cubital fossa)
• Proximal ulnar subcutaneous border
• Advantages
• More durable
• Disadvantages
• Sensation generally poor
 • Treatment Options – Cross finger flap
• For volar and distal defects
• Defects to 1.5 cm in diameter and 2.5 cm in
length
• Flap rotated from dorsum P2 region of
uninjured adjacent digits
• Paratenon left on donor site
• Donor site covered with FTSG
• Flap divided at 2+ weeks

Fingertip injuries
 Cross-finger flap

Fingertip injuries
Cross-finger flap
Cross-finger flap
Cross-finger flap
 •Treatment Options – Cross finger
flap
•Advantages
•Excellent coverage
•Covers large area
•Preserved digital length
•Disadvantages
•Insensate
•Donor site morbidity

Fingertip injuries
 •Treatment Options –
Reverse cross finger
flap
•Used for dorsal
coverage
•Flap divided at 2
weeks
•Advantages and
disadvantages similar
to cross-finger flap

Fingertip injuries
Reverse cross-finger flap
Reverse cross-finger flap
 • Treatment Options -
Thenar flap
• Young patients
• Index and long fingers
only
• Requires sustained PIP
flexion
• Flaps divided at two
weeks
• Advantages
• Single donor site
• Cosmesis
• Disadvantages
• PIP stiffness
• Limited area of
coverage
• Insensate

Fingertip injuries
• Treatment options - Volar
advancement flap
• V-Y (Atasoy)
• Palmar advancement flap for
distal defects
• < 10 mm of advancement
• Blood/nerve supply from branches
in subdermal plexus
• Kutler - bilateral advancement
flaps
• Not commonly used
• Length of remaining volar pad
must be adequate (~ ¾ length
from DIP crease to tip)
• V-shaped incision made based at
DIP crease
• V-Y flap Technique
• Distal flap sewn dorsally
• Distal limbs closed to skin
• Proximal defect closed
primarily to create
base of Y
• Advantages
• Sensate
• Donor morbidity
limited to injured finger
• Disadvantages
• Limited size
• Not appropriate for
crushing injuries
• Treatment options - Moberg advancement flap
• For thumb only
• May be advanced up to 1 cm
• Techinque
• Bilateral mid axial incisions
• Skin flap elevated off of tendon
sheath with both NV bundles
• IP flexed to advance flap
• IP is gradually straightened
• Advantages
• Similar to V-Y Flap
• Disadvantages
• IP joint contractures
• Flap necrosis if over-advanced
 • Treatment options - Moberg advancement
flap

Fingertip injuries
• Treatment options – Composite grafts
• Replacement of soft tissue (skin,
suucutaneous fat) as composite graft
• Only recommended in small children
• Survival in adults is rare but can act as
biologic dressing
 • Guidelines
• Loss of small portion of pad
• ≤ to 1 cm2  granulation, local care
• > 1 cm2  consider FTSG
• Transverse tip amputation
• Exposed bone and < 50 % nail bed loss
• Shortening with advancement of volar skin
to recreate hyponychium, primary closure
• V-Y advancement flap
• Moberg flap for thumb
• > 50 % nail bed loss
• Nail bed ablation / bone shortening
• primary closure
Fingertip injuries
 • Recommendations
• Volar oblique
• No exposed bone
• Soft tissue defect ≤ 1 cm2  granulation
• Soft tissue loss > 1 cm2  consider FTSG
• Exposed bone
• Shortening
• Cross-finger flap
• Thenar flap (young patients)

Fingertip injuries
 • Recommendations
• Dorsal oblique
• < 50 % nail bed loss
• Bone shortening and primary closure
• Bone shortening/ V-Y flap
• Bone shortening/ Moberg flap - thumb
• > 50 % nail bed loss
• Ablate nail bed/bone shortening/closure
• Nail bed ablation with reverse cross-finger
flap

Fingertip injuries
 • Complications
• Infection
• Stiffness
• Residual nail horn
• Nail deformity
• Poor quality coverage
• Poor sensibility
• Hypersensitivity
• Complex Regional Pain Syndrome
(Type 2)
Fingertip injuries