Patient Presentation
During some downtime in the pediatric clinic, a resident recounted that a 15-year-old female came to the emergency room because of a torn nail. “It really wasn’t too bad with only 2-3 mm of the nail bed area partially torn off by a door. It sort of delaminated along the nail edge but most of the nail was still there. There was little of the nail edge skin torn. She said it was painful because it would catch on something but mainly she wanted us to reattach it because she was going to the Homecoming dance in a couple of days,” he said. “So what did you do?” another resident asked. “We gave her 3 options. We could just trim the torn nail off. We could try to do a small repair using some superglue and tea bags, or we could put an adhesive bandage over it now and she could go to a manicurist the next day,” he explained. She chose the manicurist. We also recommended that she make sure to keep it clean and dry and watch for infection but there shouldn’t be much to worry about because the cut was at the nail edge and could be seen easily. It was kind of silly to be in the ER but it was different than seeing all the other colds and ear infections,” he finished.

Discussion
Distal digits, especially of the hand, are important as they provide support for pinching and grip, give tactile sensation and contribute to cosmesis. Trauma to the distal digit and nailbed ranges from significant trauma with digital crush injuries or amputation to minor broken nails causing only annoyance. Most injuries especially in children involve the hand especially the middle finger. The dominant hand is more common if the child has a hand-preference. Usually they occur indoors especially being caused by being pinched by a door.

Significant trauma requires surgical intervention and may require specialty surgical intervention by a hand specialist. Survival rates for distal digital amputations with re-implantation vary based on several factors. A 2011 systematic review of fingertip amputations found an overall 86% survival rate. Clean-cut amputations had higher survival rates than crush or crush-avulsion amputations. Actual location along the fingertip was less of a factor, but vein repair in different areas had improved survival. Nerve repair did not make a difference and recovery was good “…because of the short distance the regenerating terminal branches of the purely sensory distal nerves have to travel to reach the distal targets.” The authors note, “…the phenomenon of adjacent and spontaneous neurotization may play a role especially in younger patients.” In this systematic review, 98% returned to work, 2-point discrimination averaged 7 mm (normal 2-8 on fingertips) and complications included nail deformity (23%) and pulp atrophy (14%). Appropriate followup for surgical patients is always needed. Distal tuft injuries usually are caused by a crush without neurovascular or ligamanetous injuries and are often treated conservatively with finger splinting in a functional position and appropriate surgical followup.

Nailbed injuries again are common. Often this may be a subungual hematoma that can be quite painful. Depending on the hematoma’s extent, patients may be monitored and treated conservatively with ice and pain medication until the acute swelling resolves. Others may need minor surgical intervention (usually trephination) to release the blood under the nail. Spontaneous decompression from the nailbed’s lateral nailfold also occurs. Patients should keep the area clean, dry, and monitor it closely for infection. Patients and families should also be warned about possible complications including infection.

In 2015, a Cochrane Collaboration systematic review found insufficient evidence to avoid or recommend use of adrenaline with lidocaine for digital nerve blocks that are usually used for outpatient surgical treatment. Less bleeding and prolonged anesthesia with adrenaline use was noted but the evidence quality was low. A 2010 study of 46 consecutive serious nailbed injuries requiring surgery in children for 6 months found that 44 needed general anesthesia as the children were quite young. Two-thirds used the replaced nail as a splint for the repair. Few complications occurred at followup (15-21 months later): 3 nailbed deformities and 1 with mild aching when the digit was pressed. A review of nailbed anatomy can be found here.

Learning Point
Torn or detached nails from the nailbed usually are treated with symptomatic care with attention to minimizing pain, preventing infection and preventing further injury. Detached nails may be sutured into place to splint the digit, provide protection to the nail bed and prevent infection. Soaking the area to keep it clean and remove accumulated secretions and debris is important and antibacterial cream or petroleum jelly also keeps the area moist. However the cream/jelly should still allow normal wound secretions to drain when present in the first few days after the trauma. Partially detached nails are again left in place often by securing with an adhesive bandage that can be changed often.

Broken or torn nails may cause no problems if they are distal to the nailbed. However they commonly do common catch the edge of the nailbed causing a minor open wound that is treated conservatively and heals within a few days. If the torn nail is more proximal it may be wise to try to repair the nail. Closing up the nail on top could potentially trap infectious material so the extent of the problem versus the risk of infection should be weighed. After cleaning the digit thoroughly, the distal nail should be trimmed and filed back to prevent it catching on something and tearing more. Nail repair kits are available and should be used as directed. Usually some thin paper-like material is glued in place to splint the nail tear. A small piece of a clean (non-used) tea bag is also commonly used as an alternative and other alternatives include coffee filter, clean handkerchief linen or silk. The material is cut to fit the area (including enough to overlap the free edge of the nail if appropriate). A small amount of cyanoacrylic glue is placed over the nail tear and around the area using a small applicator or brush. The tea-bag or other material is placed on top of the glue using tweezers, smoothed and held in place to dry. Placing the paper over the free edge of the nail may also give additional support to the nail. Another small amount of glue is smoothed on top of the material. Buffing of the nail and the repair (especially going in one direction) helps to eliminate ridges or edges that could catch and disrupt the repair. Applying a clean bandage over the area can help in the first few days to remind the patient to be careful of the repair. Patients should continue to monitor the area for signs of infection.

Questions for Further Discussion
1. How fast do nails grow? A review can be found here.
2. What are indications for evaluation by a hand surgeon?
3. What initial and ongoing professional training do manicurists and cosmetologists need for their professional degrees in your area?

Related Cases

Disease: Finger Injuries and Disorders | Hand Injuries and Disorders | Toe Injuries and Disorders

Symptom/Presentation: Upper Extremity Trauma

Specialty: Dermatology | Emergency Medicine | Surgery

Age: Teenager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Finger Injuries and Disorders, Hand Injuries and Disorders and Toe Injuries and Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Pearce S, Colville RJ. Nailbed repair and patient satisfaction in children. Ann R Coll Surg Engl. 2010 Sep;92(6):483-5.

Sebastin SJ, Chung KC. A systematic review of the outcomes of replantation of distal digital amputation. Plast Reconstr Surg. 2011 Sep;128(3):723-37.

Prabhakar H, Rath S, Kalaivani M, Bhanderi N. Adrenaline with lidocaine for digital nerve blocks. Cochrane Database Syst Rev. 2015 Mar 19;(3):CD010645.

Torn or Detached Nail. C.S. Mott Children’s Hospital University of Michigan.
Available from the Internet at http://www.mottchildren.org/health-library/sig256776 (rev. 10/2016, cited 1/30/18).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa