Summary of Perionychium: Anatomy, Injuries, and Management

Perionychium: Anatomy, Injuries, & Management for Students

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Introduction

Nail surgery after trauma focuses on restoring nail bed anatomy, protecting the repair, and promoting a cosmetically and functionally acceptable nail. This guide summarizes management steps for acute nail hematomas, nail bed lacerations, avulsions, and nail bed defects, emphasizing practical techniques you can apply in the clinical setting.

Definition: Nail bed — the soft tissue under the nail plate composed of sterile matrix (ventral surface) and germinal matrix (proximal part) responsible for nail production and adherence.

Basic principles

  • Achieve good visualization (exsanguination and tourniquet).
  • Preserve and, when possible, replace the nail plate as a biologic dressing and bolster for grafts.
  • Repair nail bed under direct vision with fine sutures and minimal tension.
  • Immobilize and protect the fingertip postrepair.

Hematoma management

When to drain vs remove the nail

  • If the nail edges are intact and no obvious nail-edge disruption: drain only.
  • If the nail is broken or edges disrupted: remove nail and explore/repair nail bed.
  • Historical cutoffs (based on hematoma size) are less important than edge integrity; many hematomas do well with drainage regardless of size.

Practical steps for drainage

  1. Exsanguinate and apply a digital tourniquet.
  2. Make a hole large enough to allow continued drainage; too small a hole can reseal and lead to recurrent hematoma.
  3. If exploration is indicated, remove the nail with a periosteal elevator or scissors inserted beneath the free edge and gently advanced.

Nail bed repair: setup and general technique

  • Anesthesia: digital block with 1% plain lidocaine.
  • Asepsis: prepare and drape the hand.
  • Hemostasis: finger tourniquet at proximal phalanx.
  • Nail removal: lift nail off the bed by inserting scissors or elevator under the free edge and advancing proximally.
  • Suture material: fine monofilament such as 6-0 nylon for eponychial closure and 6-0 or 7-0 for nail bed if available.

Definition: Eponychium — the proximal fold of skin that partly covers the nail matrix; incisions here should be perpendicular to the curved fold to minimize deformity.

Repair details

  • Debride devitalized tissue; maintain as much viable sterile and germinal matrix as possible.
  • Repair nail bed lacerations with precise, eversion-producing sutures; place suture knots at the margin or edge to avoid creating ridges.
  • Replace the nail plate (or substitute) as a splint/bolster over the repaired bed.

Nail substitutes and bolsters

  • Preferred biologic bolster: the original nail plate, trimmed to allow suturing if large fragments present.
  • If original nail unavailable or too damaged: use a nail-shaped piece of 0.020-inch reinforced silicone sheeting. Silicone is less stiff and needs a nail fold suture to hold it beneath the fold.
  • If neither nail nor silicone available: a single thickness of nail-shaped nonadherent gauze or suture packet material may be used.

Practical tip: Use a horizontal mattress or similar suture through the nail wall to secure the silicone sheet in the nail fold.

Splinting and immobilization

  • Dress the finger with nonadhesive gauze and small gauze bandages; wrap with a small gauze roll.
  • Use a four-prong or volar aluminum splint for protection and pain reduction.
  • Splint wear: typically 2–3 weeks, longer if a distal phalanx fracture is present.
  • Immobilize the DIP joint only if there is a significant distal phalanx fracture.
  • Keep the finger and dressing dry and the hand elevated until follow-up.

Avulsion injuries

  • Avulsion often leaves a fragment of nail bed attached to the underside of the avulsed nail; may involve most of the nail bed.
  • In children, nail bed avulsion out of the nail fold suggests a Salter I fracture — obtain radiographs including lateral view.
  • To visualize and repair, incise the eponychium perpendicularly to the lateral curved fold, possibly on both sides.
  • Replace the avulsed nail bed as a graft with
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Nail Trauma Repair

Klíčová slova: Nail surgery: perionychium care, Nail surgery: trauma and repair, Fingertip injuries, Nail deformities, Nail disorders, Nail oncology

Klíčové pojmy: Assess nail-edge integrity to decide drainage vs nail removal, Drain hematomas with a sufficiently large hole to prevent recurrent clotting, Use the original nail as a biologic bolster when possible, Reinforced 0.020-inch silicone can substitute for nail but requires nail-fold suture, Perform nail bed repair under tourniquet with fine sutures (eg, 6-0 nylon), Split-thickness sterile matrix grafts preserve donor nail growth if harvested shallowly, Mobilize lateral paronychial folds for small central defects (<1/3 width), Harvest graft from toe when injured bed lacks >50% healthy area, Immobilize with a four-prong or volar aluminum splint for 2–3 weeks or longer if fracture, Excise scars causing chronic nonadherence before grafting, Full-thickness grafts reserved for germinal matrix replacement or salvage tissue, Keep dressing dry and hand elevated until follow-up

## Introduction Nail surgery after trauma focuses on restoring nail bed anatomy, protecting the repair, and promoting a cosmetically and functionally acceptable nail. This guide summarizes management steps for acute nail hematomas, nail bed lacerations, avulsions, and nail bed defects, emphasizing practical techniques you can apply in the clinical setting. > Definition: Nail bed — the soft tissue under the nail plate composed of sterile matrix (ventral surface) and germinal matrix (proximal part) responsible for nail production and adherence. ## Basic principles - Achieve good visualization (exsanguination and tourniquet). - Preserve and, when possible, replace the nail plate as a biologic dressing and bolster for grafts. - Repair nail bed under direct vision with fine sutures and minimal tension. - Immobilize and protect the fingertip postrepair. ## Hematoma management ### When to drain vs remove the nail - If the nail edges are intact and no obvious nail-edge disruption: drain only. - If the nail is broken or edges disrupted: remove nail and explore/repair nail bed. - Historical cutoffs (based on hematoma size) are less important than edge integrity; many hematomas do well with drainage regardless of size. Practical steps for drainage 1. Exsanguinate and apply a digital tourniquet. 2. Make a hole large enough to allow continued drainage; too small a hole can reseal and lead to recurrent hematoma. 3. If exploration is indicated, remove the nail with a periosteal elevator or scissors inserted beneath the free edge and gently advanced. ## Nail bed repair: setup and general technique - Anesthesia: digital block with 1% plain lidocaine. - Asepsis: prepare and drape the hand. - Hemostasis: finger tourniquet at proximal phalanx. - Nail removal: lift nail off the bed by inserting scissors or elevator under the free edge and advancing proximally. - Suture material: fine monofilament such as 6-0 nylon for eponychial closure and 6-0 or 7-0 for nail bed if available. > Definition: Eponychium — the proximal fold of skin that partly covers the nail matrix; incisions here should be perpendicular to the curved fold to minimize deformity. ### Repair details - Debride devitalized tissue; maintain as much viable sterile and germinal matrix as possible. - Repair nail bed lacerations with precise, eversion-producing sutures; place suture knots at the margin or edge to avoid creating ridges. - Replace the nail plate (or substitute) as a splint/bolster over the repaired bed. ## Nail substitutes and bolsters - Preferred biologic bolster: the original nail plate, trimmed to allow suturing if large fragments present. - If original nail unavailable or too damaged: use a nail-shaped piece of 0.020-inch reinforced silicone sheeting. Silicone is less stiff and needs a nail fold suture to hold it beneath the fold. - If neither nail nor silicone available: a single thickness of nail-shaped nonadherent gauze or suture packet material may be used. Practical tip: Use a horizontal mattress or similar suture through the nail wall to secure the silicone sheet in the nail fold. ## Splinting and immobilization - Dress the finger with nonadhesive gauze and small gauze bandages; wrap with a small gauze roll. - Use a four-prong or volar aluminum splint for protection and pain reduction. - Splint wear: typically 2–3 weeks, longer if a distal phalanx fracture is present. - Immobilize the DIP joint only if there is a significant distal phalanx fracture. - Keep the finger and dressing dry and the hand elevated until follow-up. ## Avulsion injuries - Avulsion often leaves a fragment of nail bed attached to the underside of the avulsed nail; may involve most of the nail bed. - In children, nail bed avulsion out of the nail fold suggests a Salter I fracture — obtain radiographs including lateral view. - To visualize and repair, incise the eponychium perpendicularly to the lateral curved fold, possibly on both sides. - Replace the avulsed nail bed as a graft with