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December 17, 2014 by dailybolusoflr
By Amanda Crichlow, MD
As we discussed in Part 1, nail removal is not necessary if the nail margins and the nail are intact.
However, the nail should be removed and the nailbed repaired if:
1) the nailbed is significantly lacerated
2) the edges of the nail are unstable
Perform a digital block before doing any of this!
Then place a finger tourniquet
HOW IS THE NAIL REMOVED?
Equipment needed: pair of small scissors and hemostat
- Hold the scissors parallel to the nailbed
- Slowly advance the closed blades of the scissors between the nail and the nailbed and gently spread the blades to the scissors to loosen the nail
- Continue to advance the scissors and spread until reaching the nail is loose
- Grasp the nail with a hemostat and pull it from the base
WHAT TYPE OF SUTURE IS USED FOR NAILBED REPAIR?
Use 6-0 or 7-0 ABSORBABLE sutures. Can do simple interrupted sutures
WHAT TO DO NEXT?
The exposed nail needs to be protected and the nail should be replaced so that:
1) It can act as a splint to maintain normal nailbed anatomy
2) It covers the sensitive nailbed and facilitates dressing changes
3) It maintains the nailfold for new nail growth
Ideally, the avulsed nail will be reapplied. If the nail can’t be used (because it’s destroyed or it didn’t come with the patient) you can use the suture packaging or gauze.
HOW TO REPLACE NAIL?
- Cleanse the nail
- Place holes in the nail edge where you want to anchor your sutures (using the technique of nail trephination as described in part 1) and also a drainage hole (so that a hematoma does not accumulate)
- Replace the nail ensuring that the proximal nail is under the cuticle and suture it in place with sutures that incorporate the skin and the nail edge using 4-0 NON-ABSORBABLE sutures
- Make sure that you the suture begins in the skin edge and then enters the nail edge and not vice versa
Sutures need to remain in place for 2-3 weeks and the new nail will begin to push the old nail out
May take up to 6 months for the new nail to be fully grown
Reichman, Eric. Emergency Medicine Procedures, 2nd edition. McGraw-Hill Education, 2013
Roberts and Hedges: Clinical Procedures in Emergency medicine, 6th Edition. Philadelphia:Saunders Elsevier, 2014