Over the years, I have been frustrated by how inelegant finger nailbed closure is. Nailbed lacerations are often sustained by a major crush injury, resulting in a stellate and irregular laceration pattern. This typically also requires the crushed fingernail to be removed. Cosmesis is never ideal because pieces of the nailbed are often missing, as seen in the photo above.
Occasionally, nailbed lacerations are caused by a cutting rather than a crush mechanism. In these cases, I use a different technique. I leave the fingernail on. In fact, I use the fingernail to help reapproximate the nailbed edges.
Trick of the Trade:
Nailbed repair through fingernail
This technique requires that the fingernail has a simple linear laceration through it. The fingernail has to be relatively still adherent to the nailbed. The case below is a patient who sustained a fingertip laceration with an industrial skill saw.
- Carefully perform a distal neurovascular exam.
- Perform a digital nerve block of the finger.
- Copiously irrigate the laceration because this is almost always an open fracture.
- Carefully create 2 holes (blue arrows) in the fingernail on either side of the laceration using electrocautery. Be careful not to injure the nailbed.
- Suture the fingernail back together by placing a non-absorbable, simple interrupted suture through the two fingernail holes. There is no need to puncture through the nailbed. Reapproximating the fingernail should also pull the nailbed edges together.
- Remove the sutures after 7-10 days.
Here is a follow-up photo of the same patient who returned 72 hours later for a wound check. Although the photo is a little fuzzy, you can see that the wound was healing well.
Advantages of this technique:
- Less traumatic repair of the nailbed
- Preservation of the eponychial fold because the native fingernail remains in place. A new fingernail can grow out normally.
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