3: Nail Bed Repair

Procedure 3 Nail Bed Repair



Pao-Yuan Lin, Sandeep J. Sebastin



Indications




image Open nail bed laceration (Fig. 3-1)


image Closed nail bed laceration with subungual hematoma involving greater than 50% of nail (Fig. 3-2)


image Closed nail bed laceration with displaced distal phalangeal fracture


image

FIGURE 3-1


image

FIGURE 3-2



Examination/Imaging



Clinical Examination




image Complete sensory examination before anesthesia.


image Note pattern of nail bed laceration (simple/stellate), involvement of germinal matrix, and dorsal roof matrix. (Fig. 3-3 shows a crush injury of the right thumb with a stellate laceration involving the sterile and germinal matrices.)


image Look out for associated subtotal pulp amputation (Fig. 3-4).


image

FIGURE 3-3


image

FIGURE 3-4



Imaging




image Radiologic examination should include anteroposterior, lateral, and oblique views of the injured fingers. (Figure 3-5 shows radiographs of the thumb depicted in Figure 3-3.)


image

FIGURE 3-5



Surgical Anatomy




image The nail is a hard structure composed of desiccated, keratinized, squamous cells attached to the nail bed and is the end product of the nail bed’s generative efforts. The nail is loosely attached to the germinal matrix but is densely adherent to the underlying sterile matrix and the eponychium.


image The nail bed is composed of sterile matrix, germinal matrix, and dorsal roof matrix (Fig. 3-6).


image The portion of nail bed beyond the lunula is the sterile matrix. The sterile matrix acts as a road bed for the advancing nail. It adds squamous cells to the nail, making it thicker, stronger, and adherent to the bed. Firm adhesion of the nail to the nail bed is essential to the function of the fingertip.


image The germinal matrix is the region of the nail bed proximal to the lunula and responsible for production of the nail plate.


image The dorsal roof matrix is the dorsal portion of the nail bed and is responsible for the luster of the nail plate.


image

FIGURE 3-6



Positioning




image The procedure is performed under tourniquet control. It can be done under local anesthesia. The patient is positioned supine with the affected extremity on a hand table.



Exposures




image A Freer elevator is inserted between the nail plate and the nail bed distally and used to elevate the nail plate off the nail bed from distal to proximal.


image Nail bed lacerations that extend under the nail fold or involve the germinal matrix require elevation of the dorsal roof matrix to expose the laceration and allow a good repair. This is done by making two oblique incisions at the corner of the nail fold and elevating the dorsal roof matrix as a proximally based flap. Two sutures at either corner maintain the flap in position (Fig. 3-7).


image

FIGURE 3-7



Pearls




In children, general anesthesia is required to facilitate a meticulous repair.


If the laceration involves only the distal portion of sterile matrix, the nail plate needs to be elevated only 1 to 2 mm beyond the laceration.


Examine the undersurface of the nail for any nail bed remnants. They can be used as a free graft.


When the dorsal roof matrix flap is sutured back, it is important to ensure that the suture passes through the full thickness of the tissue.



Pitfalls


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Mar 5, 2016 | Posted by in Hand surgery | Comments Off on 3: Nail Bed Repair

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