Introduction:
Finger injuries, including nail avulsion, are very common in Urgent Care. Anatomy knowledge is crucial when assessing possible fractures, nail bed damage, amputations, open wounds, etc. Detailed history including mechanism of injury, time of injury, the position of the digit during injury (flexion vs extension), dominant hand, occupation, previous hand procedures, surgeries or injuries and physical examination are vital steps to diagnose and manage these types of injuries properly.1,2
Case:
A 35-year-old patient presents to Urgent Care a few hours after a mechanical fall leading to a right 5th fingernail injury (lifted). She denies any other injury or head trauma, or LOC. Patient reports right 5th finger pain and edema. She denies bleeding or numbness, or weakness of the hand and fingers. She is not taking any anticoagulants and denies any pertinent past medical history, including immunocompromising conditions or bleeding disorders. The patient is not currently working and reports her right hand is dominant. She denies previous hand surgeries or injuries. The patient reports full range of motion of the finger and denies any numbness or weakness. Her last tetanus shot is unknown.
Physical examination: Vital signs are within normal limits. The patient is alert and oriented. The wrist exam is normal. The right hand shows moderate fingertip edema, no erythema, and no ecchymosis. Fifth right finger has full range of motion, normal sensation, and capillary refill. The fingernail is wholly lifted and almost entirely detached from the eponychium.
Urgent Care Management
The wound was copiously irrigated with tap water. Procedure consent was obtained. Risk and benefits of the procedure were discussed in detail, including the risk of infection and that the injured nail may look different when it grows back. Digital block was achieved with lidocaine without epinephrine. The injury was explored, and no nail bed damage was observed or signs of fracture/open wound fracture.
The nail was easily removed with forceps. Due to nail polish (acrylic), the nail was soaked in acetone for 30 – 40 min. The nail polish was partially removed from the original nail, the nail with polish material was cut, and the clean nail was placed back into the nail fold. Dermabond was used to attach the nail to the areas of the nail folds. See Figure A. The neurovascular exam was normal after the procedure. Bacitracin was applied to the finger and covered with a non-adherent gaze. The patient received tetanus.
Discussion
Fingertip injuries can be complex, but the majority can be managed in Urgent Care. Nail avulsion injuries can lead to nail bed damage. Recognizing this and repairing the nail bed when damage is observed is paramount to avoid wide scars and permanently deformed nails. It also is important to preserve the skin folds surrounding the nail margins. To prevent adhesion formation by protecting the germinal matrix, clinicians should use the original nail (if possible), non-adhesive gauze packing, sterile foil, or 0.2-inch silicone sheeting placed under the eponychium into the proximal fold, securing it with wound adhesive (least invasive) or nonabsorbable sutures. 1,2,3 Additionally, when using the original nail, clinicians must do trephination to prevent the accumulation of subungual hematomas.
Prior to repairing a nail bed laceration or fingertip amputation, radiographs (anterior-posterior and lateral) should be obtained.1 If a nail is vastly intact within the nail folds, these injuries do not need nail removal, just securing of the nail. Clinicians must communicate with patients that there is a significant risk of nail deformity even with appropriate management. 1
