NAIL BED INJURIES

Rina Dwi Purnamasari

G99142014

Dorothy Eugene Nindya G99142120

Supervisor:
dr. Amru Sungkar, Sp. B, Sp.BP-RE

INTRODUCTION
Trauma is a major cause of nail bed deformity.
Injuries include:
Subungual haematomas,
Lacerations,
Avulsion of the nail plate,
Amputation,
Paronychial tissue damage.
Even without penetrating trauma, crush injuries can result in
nail bed lacerations as the fragile nail bed tissue is squeezed
between the hard nail plate and the bone of the distal phalanx.

STRUCTURE

STRUCTURE
Perionychium The nail and surrounding structures (hyponychium,
nail bed and nail fold).
Eponychium Soft tissue on the dorsal aspect of the nail which
continues to the dorsal skin.
Lunula white arch visible on the nail distal to eponychium.
Nail bed Lies underneath the nail plate. The nail bed proximal to the
lunula is the germinal matrix and distal is the sterile matrix.
Keratinous nail growth occurs mainly from the germinal matrix.
Nail plate Keratinous nail. Its cells become anucleated and
transparent, revealing the pink underlying nail bed.
Nail fold Germinal matrix and eponychium. The fold is responsible for
shaping the nail plate as it grows distally.

CAUSES OF NAIL BED INJURIES

Both Zook et al. and Guy have
reviewed the etiology of nail
bed injuries and had very
similar findings. The majority
of these injuries occurred from
a closing door, a machine
injury, a saw injury, or by
being crushed between two
objects .

CLASSIFICATION OF NAIL BED

INJURIES
Germinal Matrix Injury:

GI: Small subungual hematoma proximal nail (25%)

GII: Germinal matrix laceration, large subungual hematoma (50%)
GIII: Germinal matrix laceration and fracture
GIV: Germinal matrix fragmentation
GV: Germinal matrix avulsion

Sterile Matrix Injury:

SI: Small nail hematoma (50%)

SII: Sterile matrix laceration, large subungual hematoma (50%)
SIII: Sterile matrix laceration with tuft fracture
SIV: Sterile matrix fragmentation
SV: Sterile matrix avulsion

TYPE OF INJURIES
Subungual Haematoma
Subungual haematoma is usually caused by crush injuries, leading to the
formation of a collection of blood between the nail bed and the nail plate.
If the surface area of the haematoma is <25% and the patient is
asymptomatic with no underlying fracture can be managed
conservatively (Yeo et al., 2010).
If the affected surface area is 2550% or if the patient is symptomatic,
requires evacuation by trephination.
Haematomas covering > 50% with underlying distal phalynx fractures
have traditionally been treated with surgical repair involving removal of
the nail and suturing the underlying laceration (Gaston and
Chadderdon, 2012).
However, recent evidence suggests that, simple trephination has a
similar prognosis to surgical repair (Roser and Gellman, 1999).
Additionally, trephination causes less pain and a shorter stay in

Subungual Haematoma

Trephination is a technique that involves making a small

hole in the nail plate over the site of the haematoma to
allow the blood to escape.

Nail Bed Avulsions

Ideally, the avulsed nail bed is
sutured in an anatomic position.
Often, the nail bed is attached to
the nail plate. A decision must be
made whether to separate the nail
bed from the nail plate or suture
the nail bed and plate as one unit.
If the pieces are small, we tend to
suture the nail bed and plate as one
segment. If the fragment of the
avulsed nail bed is large, it is
carefully separated from the nail
plate. The nail bed can be sutured
directly onto bone.

Incomplete Avulsions
Incomplete avulsion of the nail
bed often occurs at the germinal
matrix. A bending force through
the distal phalanx is transmitted
proximally to avulse the germinal
matrix and displace the nail from
beneath the nail fold. In the past,
the distal nail was left in place
and the proximal avulsed nail bed
was reapproximated. At present,
elevation of the entire nail to
ascertain the degree of injury and
repair is recommended.

Split Nail
Split nails occur because of a longitudinal
scar in the germinal or sterile matrix. The
nail, therefore, grows on either side of the
scar in the germinal matrix. The scar in the
sterile matrix leads to nonadherence, and
increased stresses in the nail causes the split
or crack.
Reconstructing a split nail is similar in
principle to treating nonadherence. If the
split is in the sterile matrix or distal germinal
matrix region, the scar is excised and
replaced with a split-thickness matrix graft.
A split nail due to an abnormality in the
germinal matrix requires a germinal matrix
graft, which can be harvested from another
finger or toe. Both have the complications of
persistent
deformity
and
donor
site
morbidity.

Linear Ridging
Linear ridging is often secondary to a
bony protuberance beneath the nail
bed. As described by Kleinert, the
treatment in this setting involves
incising the nail bed over the involved
area. An ostectomy is performed, and
the nail bed reapproximated. Shepard
has reported good results in six
patients with this technique

Lateral Deviation
Lateral deviation of the nail is due to
a full-thickness avulsion of the
lateral aspect of the nail bed with
displacement.
Rather than rotating a portion of the
nail bed into the defect, the
recommended management involves
elevation of the entire nail bed and
placing it in a straight position.

Total Nail Loss

A hooked nail involves volar Total nail loss can be treated
by split-thickness skin grafting, nail prosthesis, or total nail
reconstruction. Total nail reconstruction involves transfer of
the nail bed as a free or vascularized nail graft. The free
graft can be taken by elevating the nail plate and
harvesting the nail bed and matrix as far as the proximal
end of the nail matrix.
In free nail grafts, Shepard notes the importance of taking
the proximal nail fold. All patients in his series in which this
was not incorporated would have failed. When the proximal
nail fold was incorporated, he had a 50% success rate (37).
The lateral edge of the great toe is often the donor site.
The donor site is covered with a split-thickness skin graft.

WORKUP
X-Ray Examination
It depends on area of wound.
Anteroposterior, lateral, and oblique view of X-Ray
fracture, dislocation of finger, or corpal

TREATMENT OF NAIL BED

INJURIES
Principles of treatment include minimal debridement, preservation of as
much tissue as possible, atraumatic wound care, and splinting with the
nail or an alternative material.

THANK YOU