Nail bed injuriesMANAGEMENT

FOREARM, WRIST & HAND · 12 SECTIONS

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533 items

☷ Legend

01Approach to the Critical Patient/attcp40

Immediate priorities

›Time-critical priorities

›Active bleeding

›Direct pressure

›Finger tourniquet time awareness

›Neurovascular threat

›Pale or cool digit

›Cap refill delay

›Open injury

›Antibiotics timing

›Tetanus status

›Severe crush or avulsion

›Hand surgery escalation

Pain control and anesthesia

›Analgesia and anesthesia

›Immediate analgesia

›Acetaminophen PO

›NSAID PO if safe

›Digital nerve block

›Lidocaine 1% or 2% without epinephrine

›Bupivacaine 0.25% for longer duration

›Maximum local anesthetic dose reference

›Lidocaine without epinephrine 5 mg/kg

›Lidocaine with epinephrine 7 mg/kg

›Bupivacaine 2.5 mg/kg

›Procedural sedation triggers

›Uncooperative patient

›Extensive debridement

›Complex nail bed repair

›ACEP procedural sedation guidance alignment

Limb and digit threat concepts

›Limb and digit threat framework

›Distal phalanx open fracture equivalence

›Nail bed laceration with distal phalanx fracture treated as open fracture pathway

›Antibiotics and tetanus logic

›High-risk associated injuries

›Tendon injury

›Seymour fracture suspicion in pediatrics

›Pre and post intervention documentation

›Motor function

›Sensory function

›Cap refill

›Two-point discrimination when feasible

02History/hx39

Mechanism and timing

›Injury context

›Mechanism pattern

›Crush in door

›Laceration by sharp object

›High-energy tool injury

›Sports ball impact

›Time since injury

›Hours since injury

›Prior attempts at drainage or repair

›Contamination

›Soil or farm exposure

›Freshwater exposure

›Saltwater exposure

›Hand dominance

›Dominant hand involvement

›Occupational demands

Symptoms and function

›Symptom pattern

›Pain severity trajectory

›Increasing pain despite immobilization

›Pain out of proportion concern

›Numbness or tingling

›Digital nerve concern

›Cold intolerance new onset

›Nail symptoms

›Subungual pressure sensation

›Nail avulsion or loose nail plate

›Functional limitation

›Inability to flex DIP

›Inability to extend DIP

Medical risks and modifiers

›Patient factors

›Diabetes

›Peripheral vascular disease

›Immunosuppression

›Smoking

›Anticoagulants or antiplatelets

›Tetanus immunization status

›Allergy profile

›Beta-lactam allergy

›Local anesthetic allergy

03Physical Exam/exam48

Inspection and skin

›External assessment

›Nail plate position

›Intact

›Partially avulsed

›Completely avulsed

›Subungual hematoma

›Percent nail surface estimate

›Nail fold integrity

›Nail fold and periungual skin

›Paronychial fold laceration

›Eponychial fold disruption

›Tenting or threatened skin

›Wound contamination

›Foreign material

›Grease or paint

Neurovascular and function

›Neurovascular and tendon checks

›Perfusion

›Cap refill

›Color and temperature

›Distal pulse if proximal injury concern

›Sensation

›Radial digital nerve distribution

›Ulnar digital nerve distribution

›Two-point discrimination when feasible

›Motor

›DIP flexion

›DIP extension

›PIP motion

›Compartment style concerns in digit

›Tense pulp

›Escalating pain

Nail bed specific findings

›Nail bed injury characterization

›Laceration depth clues

›Visible nail bed split

›Persistent bleeding from under nail plate

›Nail matrix injury clues

›Proximal nail fold disruption

›Nail plate displaced proximally

›Fracture clues

›Distal phalanx point tenderness

›Rotational deformity

›Mallet posture

PITFALLS

›Common pitfalls

›Missed distal phalanx fracture with subungual hematoma

›Missed Seymour fracture in pediatrics

›Nail plate removal without preserving nail fold space

›Overlooking foreign body under nail plate

›Inadequate anesthesia leading to poor repair quality

04Differential Diagnosis/ddx42

Traumatic nail unit conditions

›Nail unit differential

›Subungual hematoma

›Isolated without laceration

›Associated nail bed laceration

›Nail bed laceration

›Sterile matrix involvement

›Germinal matrix involvement

›Nail plate avulsion

›Partial

›Complete

›Nail fold laceration

›Paronychia fold

›Eponychium fold

›Distal phalanx fracture

›Tuft fracture

›Shaft fracture

›Intra-articular fracture

High-risk mimics and co-injuries

›Mimics and co-injuries

›Seymour fracture

›Salter-Harris I or II distal phalanx with nail bed injury

›Open fracture behavior

›Mallet finger

›Extensor tendon injury

›Bony mallet fracture

›Flexor digitorum profundus avulsion

›Jersey finger

›Digital nerve laceration

›Digital artery injury

›Foreign body

›Metal

›Glass

›Wood

Coding anchors

›Coding concepts

›ICD-10 nail bed laceration

›S61.3 open wound of finger without damage to nail

›S61.1 open wound of finger with damage to nail

›ICD-10 distal phalanx fracture

›S62.6 fracture of other and unspecified parts of fingers

›SNOMED CT concepts

›Nail bed laceration

›Subungual hematoma

›Distal phalanx fracture

05Laboratory Tests/lt19

Routine testing

›Laboratory testing strategy

›No routine labs for isolated nail bed injury

›Normal vitals

›No significant bleeding

Conditional testing

›Scenario-based labs

›Significant bleeding or anticoagulation

›Hemoglobin

›Platelets

›INR if warfarin use

›Infection concern

›No routine CBC for uncomplicated wounds

›CBC if systemic illness

›Crush injury with prolonged entrapment

›Creatine kinase

›Creatinine

›Potassium

PITFALLS

›Lab limitations

›Normal labs do not exclude open fracture infection risk

›INR alone does not predict wound bleeding severity

06Diagnostic Tests/dt41

Scoring Systems

›Classification frameworks

›Seymour fracture identification

›Pediatric distal phalanx physeal fracture with nail bed disruption

›Open fracture management implications

›Salter-Harris classification

›Type I distal phalanx physis injury

›Type II distal phalanx physis injury

›Gustilo-Anderson open fracture concept application

›Nail bed laceration with fracture as open fracture behavior

›Contamination guiding antibiotic breadth

Radiographs

›Plain radiography

›Indications

›Significant subungual hematoma with distal tenderness

›Nail bed laceration

›Nail avulsion

›Mallet posture

›Views

›Finger AP

›Finger lateral

›Finger oblique

›Key findings

›Tuft fracture

›Physeal injury in pediatrics

›Volar displacement suggesting Seymour fracture

›Intra-articular extension

›Post-repair imaging needs

›Post-reduction films if DIP alignment manipulated

MRI

›MRI role

›Not routine for acute nail bed trauma

›Delayed evaluation

›Suspected tendon rupture with normal radiographs

›Chronic pain with suspected occult fracture

›Limitations

›Access and timing mismatch for acute ED care

›CT role

›Not routine for isolated distal phalanx injuries

›Indications

›Complex intra-articular fracture on radiographs

›Surgical planning in severe comminution

›Limitations

›Radiation and low incremental yield for most tuft fractures

07Disposition/dispo29

Discharge criteria

›Safe discharge features

›Stable vitals

›Pain controlled with oral regimen

›No neurovascular compromise

›Wound cleaned and repaired or appropriately managed

›Splint or protective dressing applied

›Clear follow-up plan

Admission and transfer triggers

›Escalation criteria

›Seymour fracture suspected or confirmed

›Urgent hand surgery consultation

›Operative irrigation and debridement pathway

›Open fracture with heavy contamination

›IV antibiotics consideration

›Specialist involvement

›Vascular compromise

›Immediate hand surgery or transfer

›Complex nail bed injury

›Germinal matrix disruption

›Large avulsion with tissue loss

›Uncontrolled pain or inability to perform repair safely

Follow-up timing

›Follow-up targets

›Simple trephination only

›Primary care or hand clinic follow-up as needed

›Nail bed repair

›Hand surgery or plastics follow-up in 5 to 10 days

›Distal phalanx fracture

›Hand or fracture clinic per local pathway

›Splint checks

›Dressing recheck within 48 to 72 hours if bulky dressing

08Treatment/t137

Immediate life-saving interventions

›Immediate stabilization actions

›Bleeding control

›Direct pressure

›Hemostatic dressing consideration

›Constriction relief

›Ring removal

›Tight band removal

›Gross contamination management

›Irrigation before definitive repair when feasible

›Cover open wounds with sterile dressing

Immobilization and Splinting

›Protection and immobilization

›Splint selection

›Distal phalanx fracture protection

›DIP extension splint

›Finger stack style splint

›Soft tissue only injury

›Bulky dressing with fingertip protection

›Immobilization principles

›DIP immobilization

›PIP free when possible

›Elevation

›Post-immobilization checks

›Cap refill

›Sensation

›Active motion of non-immobilized joints

Reduction

›Alignment management

›Reduction indications

›DIP malalignment with fracture

›Seymour fracture realignment needs

›Reduction cautions

›Pediatric physis vulnerability

›Open fracture behavior

›Analgesia and anesthesia

›Digital block first-line

›Lidocaine 1% without epinephrine

›Typical volume per side 1 to 2 mL

›Maximum dose adherence

›Bupivacaine 0.25%

›Longer duration option

›Maximum dose adherence

›Procedural sedation pathway if needed

›Continuous monitoring

›Airway readiness

›Post-reduction requirements

›Neurovascular reassessment

›Immobilization in stable position

›Post-reduction radiographs when alignment changed

›Failed reduction pathway

›Persistent malalignment

›Persistent neurovascular deficit

›Immediate specialist escalation

Open fracture medications and timing

›Antibiotics and tetanus

›Antibiotics timing concept

›As early as feasible for open fracture behavior

›Oral regimen for low-grade contamination when appropriate

›First-line oral coverage

›Cephalexin PO

›Adults 500 mg every 6 hours

›Pediatrics 25 to 50 mg/kg/day divided every 6 to 8 hours

›Typical duration 3 to 5 days per local protocol

›Alternative oral coverage

›Amoxicillin-clavulanate PO

›Adults 875 mg every 12 hours

›Pediatrics 25 to 45 mg/kg/day as amoxicillin component divided every 12 hours

›Bite or heavy contamination consideration

›Beta-lactam allergy option

›Clindamycin PO

›Adults 300 to 450 mg every 6 to 8 hours

›Pediatrics 20 to 30 mg/kg/day divided every 6 to 8 hours

›MRSA risk option per local epidemiology

›Doxycycline PO

›Adults 100 mg every 12 hours

›Avoid in children under 8 years

›Tetanus prophylaxis

›Clean minor wound and immunized

›Booster if last dose over 10 years

›Dirty wound or open fracture behavior

›Booster if last dose over 5 years

›Unknown or incomplete immunization

›Tetanus immune globulin per standard dosing

›Vaccine initiation

DVT prophylaxis when relevant

›VTE considerations

›Not indicated for isolated finger injuries

›High-risk immobilization exceptions

›Polytrauma admission pathway

›Additional lower limb immobilization

Local wound care and nail bed repair

›Trephination pathway

›Indications

›Painful subungual hematoma

›Intact nail folds

›No gross nail plate disruption

›Technique options

›Thermal cautery device

›Large-bore needle twist

›Contraindications

›Suspected nail bed laceration with displaced nail plate

›Acrylic nails with ignition risk for thermal method

›Concern for Seymour fracture

›Post-trephination care

›Light dressing

›Re-accumulation warning signs

›Nail plate removal criteria

›Nail plate avulsion or gross disruption

›Nail bed laceration visible or strongly suspected

›Proximal nail fold injury

›Seymour fracture suspicion in pediatrics

›Nail bed repair principles

›Irrigation and debridement

›Copious saline irrigation

›Foreign body removal

›Repair material

›Absorbable suture for nail bed

›6-0 or 7-0 absorbable monofilament

›Tissue adhesive option for simple linear splits

›Low-tension wounds

›Dry field requirement

›Nail fold stent concept

›Replace cleaned native nail plate if available

›Substitute stent if nail plate not usable

›Nonadherent foil or sterile plastic

›Secure with suture through nail plate or stent

›Hemostasis strategies

›Brief tourniquet use

›Release and reassess perfusion before dressing

›Dressing strategy

›Nonadherent layer

›Bulky protective wrap

›Splint if fracture present

›Fracture management add-ons

›Tuft fracture

›Protective splinting

›Wound management as primary driver

›Seymour fracture

›Urgent hand surgery

›Antibiotics

›Irrigation and debridement

›Reduction and stabilization as needed

09Special Populations/sp40

Pregnancy

›Pregnancy considerations

›Analgesia selection

›Acetaminophen preferred

›NSAID avoidance in later pregnancy per obstetric guidance

›Antibiotic selection

›Beta-lactams generally compatible

›Tetracycline avoidance

›Imaging considerations

›Finger radiographs with shielding as needed

›Radiation dose low for extremity imaging

›Tetanus vaccination

›Standard wound prophylaxis alignment

Geriatric

›Older adult considerations

›Fragile skin and delayed healing

›Gentle debridement

›Lower threshold for follow-up

›Anticoagulation

›Bleeding risk planning

›Hematoma re-accumulation risk

›Infection risk modifiers

›Diabetes

›Vascular disease

›Pain medication risks

›NSAID renal and GI risk

›Opioid delirium risk

Pediatrics

›Pediatric considerations

›Seymour fracture vigilance

›Low threshold for radiographs

›Nail plate trapped at physis clue

›Growth plate protection

›Gentle reduction technique

›Specialist referral thresholds

›Weight-based dosing

›Local anesthetic maximum mg/kg

›Antibiotic mg/kg dosing

›Nonaccidental trauma context

›Inconsistent mechanism

›Multiple injuries

›Nail regrowth expectations counseling

›Temporary nail dystrophy risk

10Background/b41

Epidemiology

›Epidemiology context

›Common ED hand injury subtype

›Frequent association with distal phalanx tuft fractures

›High prevalence mechanisms

›Door crush injuries

›Tool and workplace injuries

›Complication themes

›Nail deformity

›Infection in open fracture behavior

›Chronic tenderness

Pathophysiology

›Nail unit anatomy and injury mechanics

›Nail plate and bed relationship

›Nail plate as rigid cover

›Nail bed as vascular tissue prone to bleeding

›Matrix injury consequences

›Germinal matrix injury causing permanent deformity risk

›Sterile matrix injury affecting nail adherence and surface

›Subungual hematoma pressure physiology

›Pain driven by pressure under nail plate

›Trephination relieving pressure

›Distal phalanx fracture linkage

›Nail bed laceration bridging to bone exposure behavior

›Open fracture infection risk concept

Therapeutic Considerations

›Treatment rationale

›Trephination value

›Pain relief

›Low complexity when nail folds intact

›Nail bed repair value

›Nail growth surface restoration

›Nail deformity risk reduction

›Nail fold stenting value

›Prevents adhesion of eponychial fold

›Maintains nail plate track

›Antibiotic rationale in open fracture behavior

›Bone exposure risk in distal phalanx fracture with nail bed laceration

›Contamination burden guiding regimen breadth

›Evidence framing

›Trephination acceptable for painful subungual hematoma with intact nail folds when no displaced nail plate

›Hand surgery consensus supports meticulous nail bed repair for matrix injuries

›Antibiotic practice varies for tuft fractures with nail bed laceration

›Local protocol alignment recommended

11Patient Discharge Instructions/pdi34

copy discharge instructions

›Discharge instructions

›Wound care

›Keep dressing clean and dry for 24 to 48 hours

›After 24 to 48 hours, gentle soap and water if advised

›Nonadherent dressing changes as instructed

›Elevation and swelling control

›Hand elevation above heart

›Ice over dressing in short sessions

›Pain plan

›Acetaminophen as directed

›NSAID as directed if safe

›Avoid exceeding maximum daily doses

›Splint care

›Keep splint dry

›Loosen wrap if increasing tightness

›Activity limits

›No heavy lifting or contact use of injured finger

›Splint adherence if fracture present

›Infection warnings

›Increasing redness

›Increasing warmth

›Pus or foul drainage

›Fever

›Neurovascular warnings

›Increasing numbness

›Increasing tingling

›Finger turning pale or blue

›Worsening pain not controlled by medication

›Hematoma warnings after trephination

›Rapid re-accumulation of pressure pain

›Persistent bleeding soaking dressings

›Follow-up plan

›Repair follow-up in 5 to 10 days

›Earlier review if dressing issues or worsening symptoms

12References/r23

Clinical guidelines and evidence sources

›Key sources

›Hand surgery and plastics principles for nail bed repair and nail fold stenting

›Textbook and society practice standards

›Specialist consensus recommendations

›Open fracture principles

›ATLS framework for traumatic wounds

›Open fracture antibiotic and tetanus timing concepts

›ACEP procedural sedation clinical policy

›Sedation monitoring and safety standards

›Airway readiness requirements

Evidence grading notes

›Evidence levels framework

›ACEP Level A

›High-quality evidence support

›ACEP Level B

›Moderate evidence support

›ACEP Level C

›Consensus and limited evidence support

›ACC AHA Class I

›Benefit much greater than risk

›ACC AHA Class IIa

›Benefit greater than risk

›ACC AHA Class IIb

›Benefit at least equal to risk

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed March 6, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.