Review articleAcute nail bed injuries
Section snippets
Anatomy and physiology
The anatomy and physiology of the perionychium has been well described by Zook and associates, as well as in the initial article in this volume of the Hand Clinics [1]. A thorough understanding of the anatomy and physiology of the nail complex is necessary to adequately manage the acute nail bed injury (Fig. 1).
The perionychium consists of the nail folds as well as the nail plate, nail bed, and the hyponychium. The nail fold consists of the nail wall, the eponychium, and the dorsal roof of the
Causes of injury
There are numerous causes of nail deformities; however, the acute nail deformity usually is the result of trauma. and trauma by far is the leading cause of both acute and chronic nail bed deformities [2], [3]. Other causes of nail disruption are iatrogenic or self-inflicted injuries, infection, tumors, and congenital problems.
Traumatic injuries to the nail bed can occur from sharp lacerations, but more commonly occur from crush injuries such as the fingertip being crushed between two heavy
Types of injuries
Injuries to the perionychium can be categorized both by the nature of the injury as well as the anatomic location of the injury. The nature of the various injuries was previously mentioned in the proceeding section. These include simple lacerations, complex stellate lacerations, avulsion injuries, amputations, or associated paronychial injuries such as distal phalangeal fractures or nail wall injuries.
A thorough understanding of the anatomy of the perionychium is requisite for a good outcome.
Evaluation of nail bed injuries
The initial evaluation of a nail bed injury generally occurs in an office or emergency room setting (Fig. 6). The injured finger can generally be examined without anesthesia, although in a young patient or one with severe pain, a digital block can be performed initially before examining the fingertip. Oftentimes a block is necessary before the finger can be cleansed enough to actually identify the structures that are injured. If the plate is avulsed out of the folds and is unstable, more than
Paronychial laceration or avulsion
Injuries to the paronychium are quite common with nail bed injuries. Simple lacerations should be repaired primarily prior to repair of any associated nail bed injury. With complete avulsion or amputation of a portion of the paronychium or nail bed, replacement with either a local flap or regional flap may be necessary to provide adequate support and coverage for the fingertip. This may be necessary before any definitive nail bed repair. Most commonly used flaps for this are the volar VY
Summary
Although many consider the fingertip injury a very mundane and simple problem, the mismanagement of this injury can often lead to a chronic esthetic and possibly painful deformity. As noted in this article, the appropriate understanding of the involved structures of a fingertip injury as well as the meticulous management of these injuries can generally lead to a very esthetic and functional fingertip. As previously noted by Elvin Zook, there is probably nowhere that Meskimen's Law, “There is
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