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reimplantation by a surgeon for amputations proximal to the distal
interphalangeal joint (see Chapter 109 Hand Trauma ).

Nail Bed Lacerations
Trauma to the distal fingers is often associated with nail and nail bed (matrix)
injuries. Nail avulsion can be partial or complete and may or may not be
associated with nail bed laceration. An underlying fracture of the distal phalanx
may also be present, so an x-ray is recommended prior to any repairs. Generally,
minor tuft fractures will heal with splinting and do not require an initial surgical
evaluation. Injury to the fingertip is often associated with subungual hematoma.
In evaluating these injuries, the emergency provider should determine the need to
explore the nail bed for a laceration. Unrepaired nail bed lacerations may
permanently disfigure the growth of the new nail from the cicatrix nail bed. If the
nail is partially avulsed but is firmly attached to its bed, exploring the nail bed is
difficult and is probably not warranted. Good outcome is expected because the
nail holds the underlying lacerated nail bed tissues in place.
When the nail is completely avulsed or is attached loosely, remove the nail and
assess the nail bed for laceration. If the nail bed is lacerated, repair it using 6-0
absorbable material or skin adhesive. Traditional approaches have included
splinting the nail fold (eponychium) away from the nail bed. This is accomplished
by cleansing and trimming the soft proximal portion of the nail, and inserting it
into the original space. It can then be anchored into place with sutures or skin
adhesive. If the nail itself is too damaged to replace, a nonadherent sterile gauze
or sterile foil from a suture packet can be placed carefully under the nail fold.
Preservation of this space may help the new nail grow undisturbed (see Chapter
109 Hand Trauma ). The preferred method of anesthesia for nail bed repair is a
digital block, and the use of a finger tourniquet during the repair allows a
bloodless field. The repaired fingertip can be dressed with sterile petrolatumimpregnated gauze and covered with sterile dry dressing. A finger splint after
repair is recommended if there is an associated fracture or for added protection
against reinjury in young children.
Consultation with a hand specialist is recommended if the fingertip injury

includes a large or complex laceration, an associated tendon injury, a fracture
other than a minor tuft fracture, a dislocation or amputation with exposure of
bone, or if there is any question about the optimal management. After repair of
fingertip injuries, small lacerations can be followed up by the primary care
provider. All other injuries should see a hand specialist to ensure appropriate
healing.