() 2007 Lippincott Williams & Wilkins, Philadelphia
Techniques in Hand and Upper Extremity Surge~y 1 1(2):135-138, 2007
•
TECHNIQUE
•
Avulsion Injuries of the Nail Bed Do Not Need
Nail Bed Graft
Olayinka Ogunro, MD
Methodist Charlton Medical Center
Dallas, TX
Shade Ogunro, BA
Temple University Medical School
Philadelphia, PA
• ABSTRACT
From 1985 to 1992, 12 cases of severe avulsion injuries of
the nail bed were treated by allowing the nail bed to
regenerate naturally, without a nail bed graft irrespective
of the extent of nail bed loss. This involved simply
covering the residual nail bed with the nail splint for a
period of approximately 6 weeks or until the nail bed was
observed to be fully regenerated. The patients were then
followed up until full nail growth. It was observed that the
nail bed regenerated spontaneously, followed by a normal
nail growth identical to the contralateral uninjured nail.
Proper coverage of the nail bed protected the culture
milieu conducive to natural nail bed regeneration, and
nail bed grafting was not necessary irrespective of the
extent of tissue loss.
Keywords: avulsion , nail bed injuries, bed, grafting
n 1955, Flatt brought our attention to the fact that
when acute nail bed injuries were allowed to heal by
secondary intention, poor results were obtained. These
injuries were simply treated by dressing with resultant
desiccation of the residual nail bed and its culture
media. Since then various types of graft I- 3 have been
used in the treatment of these injuries. The most
successful to date has been the use of split thickness
nail grafts as described by Sheppard.4
Ogo, 5 however, reported spontaneous regeneration
of the nail bed in avulsion injuries that were treated
without nail bed graft after amputation at the level of the
cuticle. In 3 of the 4 cases presented, the amputated
stump was covered with a flap. In the fourth case, a full
thickness graft was used to cap the amputated stump.
Despite this, avulsion injuries of the nail bed have
continued to be treated with nail bed graft, often obtained
rr
Address correspondence and reprint requests to Olayinka Ogunro,
MD, Hand and Upper Extremity Center, 7989 W. Virginia Drive,
Dallas, TX 75237. E-mail: [email protected].
Supported by Inro Medical Designs, Desoto, TX.
from an uninjured toe and thus compounding the patient's
original injury by inflicting another injury. The authoritative
texts in hand surgery continue to advocate this method.
The purpose of this study is to demonstrate that the
nail bed has a strong regenerating capacity, and hence,
avulsion injuries of the nail bed do not need grafting. In
this study, it was noted that when the nail bed was
protected with a cover, desiccation was avoided, and the
hematoma that formed beneath it became organized into
a nail bed with all its natural physiological properties.
Based on this observation, we concluded that nail bed
grafting is not necessary in acute avulsion injuries of the
nail bed as long as a suitable coverage was used to protect
the hematoma and the culture media conducive to nail
bed regeneration.
• MATERIALS AND METHODS
From 1985 to 1992, 12 fingers with acute avulsion injuries
of the nail bed were treated in 12 patients (Table 1). These
patients were all males with severe industrial trauma to
their digits. All injuries presented with the avulsion of
the nail bed with an intact germinal matrix except for
case 9 (Fig. 1), where at least 50% of the germinal
matrix was avulsed.
There were 5 associated phalangeal fractures, 3 of
which involved loss of the dorsal cmtex of the distal
phalanx (Fig. 1, case 9, and Fig. 2, case 10).
There were 8 cases of pulp avulsions (Table 1), 3 of
which necessitated cross finger pedicle flap, and 5
needed a V-Y flap (Fig. 2, case 10, and Fig. 3, case 3).
• OPERATIVE TECHNIQUE
The technique consisted of general debridement and
repair of the nail bed wherever possible. The segment of
the nail bed loss was not grafted. It was simply covered
by the nail splint and secured in place by applying
proximal sutures of 5-0 nylon through the eponychium
to exit in the nail fold, taking care to avoid suturing the
Volume 11, Issue 2
135
Ogunro and Ogunro
TABLE 1. Summary of Cases
Case Age Sex Digit
1
19
M
L.I
Type of
injury
Associated
injuries
Pulp loss
Date of
injury
Avulsion
3/2/1985
loss nail
bed tissue
6/20/1985
Pulp loss
2
28 M L.V Avulsion
loss nail
bed tissue
26 M L. III Avulsion
Pulp loss
3
8/9/1985
and distal
loss nail
phalanx fx.
bed tissue
Avulsion
1013111988
4
23 M L.I
loss nail
bed tissue
Fx. Distal
11/2311988
20 M L.III Avulsion
5
loss nail
phalanx
bed tissue
6
41 M R.III Avulsion
3110/1989
Distal and
middle
loss nail
phalanx fx .
bed tissue
7
54 M R. III Avulsion
Pulp loss
10/19/1989
loss nail
bed tissue
10/23/1989
Pulp loss
8
39 M L.III Avulsion
loss nail
bed tissue
Loss dorsal 11128/1989
59 M L.III Avulsion
9
loss nail
cortex
bed tissue
Pulp loss
10
32 M L.III Avulsion
6/411990
loss nail
bed tissue
11
51 M L.III Avulsion
Pulp loss
6/22/1990
loss nail
bed tissue
Fx. Distal
11120/1990
12
33 M L.III Avulsion
loss nail
phalanx
bed tissue
ORIF indicates open reduction and internal fixation; fx., fracture.
3/2/1985
Associated · Follow-up
surgery
in months
Nail splint Pedicle flap
8 mo
6/20/1985
Nail splint
Pedicle flap
Lost at
3 mo
8/9/1985
Nail splint
V-Y Flap
12mo
Full nail
regeneration
10/31/1988
Nail splint
8 mo
Full nail
regeneration
11/23/1988
Nail splint Pedicle flap
1y
Full nail
regeneration
6mo
Full nail
regeneration
Date of
surgery
3/10/1989
Surgery
Repair splint Bone graft
ORIF
Results
Full nail
regeneration
10/19/1989
Nail splint
V-Y flap
6y
Full nail
regeneration
10/23/1989
Nail splint
V-Y flap
6mo
Full nail
regeneration
11128/1989
Nail splint
6y
Full nail
regeneration
6/411990
Nail splint
V-Y flap
1y
Full nail
regeneration
6/22/1990
Nail splint
V-Y flap
Lost to
follow-up
11120/1990
Nail splint
ORIF
distal
phalanx
1y
Full nail
regeneration
germinal matrix. The suture is then passed through the
lateral drainage hole in the splint and then passed
retrograde through the fold to exit on the eponychium.
Using the same technique, a second suture is applied
through the medial drainage hole. Gentle traction on the
suture ends will seat the nail splint in the eponychial fold .
FIGURE 1. Case 9. Avu lsion of nail bed with 50% loss of
the germinal matrix and loss of dorsal cortex of the distal
phalanx.
FIGURE 2. Case 10. Avu lsion of the nail bed with loss of
segment of distal phalanx. V-Y flap has been performed.
136
Techniques in Hand and Upper Extremity Surgery
Avulsion Injuries of the Nail Bed
FIGURE 3. Case 3. Avulsion of the nail bed, loss of the
terminal end of the distal phalanx and pulp. V-Y flap in place.
FIGURE 5. Case 10. Three weeks after splinting. Spontaneous regeneration of the nail bed. The nail is regenerating.
Ten fingers were followed up until full nail bed
regeneration and nail growth. Two patients failed to
follow up. The follow-up ranged from 6 months to 6
years. After the surgical procedure, a hematoma formed
in the "dead space" beneath the nail splint. The excess
blood drained through the drainage holes. The hematoma
retained its physiological characteristics, and desiccation
did not occur. At approximately 1 week, the hematoma
became more organized and firm in its consistency and
could not be dislodged. At approximately 3 weeks,
almost complete ingrowth of nail bed tissue could be
observed replacing the hematoma (Fig. 5, case 10).
The regenerated nail bed was grossly similar to the
natural nail bed and demonstrated the sensitivity
characteristic of the nail bed. By 6 weeks when the
splint and sutures were removed, there was no gross
difference between the regenerated nail and the residual
nail tissue. Histological studies obviously could not be
performed. At this time, the nail was noted to have
regenerated approximately 4 rmn distal to the eponychium, and further nail growth continued until
restoration of its full length. This pattern of reconstitution of the hematoma into the nail bed followed by
regeneration of the nail was observed in all the digits
(Figs. 5 and 6). All the digits demonstrated regeneration
of the nail bed and nail, which was equal to or within
2 mm of the original nail length, when compared with
the uninjured contralateral side (see Fig. 7). In patients
FIGURE 4. Case 3. The splint used for coverage without
nail bed graft. The distal end of the V-Y flap was sutured
to the distal end of the splint. Proximal suture placement.
FIGURE 6. Case 9. At 6 weeks, the nail bed is
completely regenerated without a nail bed graft. The
new nail is also regenerating.
Distal sutures are then applied as desc1ibed by Ogumo!
The splint was trirmned to a length similar to the length of
the uninured nail on the contralateral side, thus restoring
some length to the regenerating nail bed (Fig. 4, case 3).
Where V-Y flap or distal flaps were necessary, the flaps
were sutured to the distal end of the splint instead of the nail
bed (Figs. 2 and 4). This prevented palmar traction on the
nail bed and served as a firm support for the flaps and
preserved the "dead space," which became filled with
hematoma and organized into the regenerating nail bed.
Appropriate dressing was appled for a period of 2 weeks
and then followed by the use of a protective Stack splint.
The nail splint was removed at approximately 6 weeks or
when the nail bed was observed to be fully regenerated as .
perceived through the transparent splint.
•
RESULTS
Volume 11, Issue 2
137
Ogunro and Ogunro
FIGURE 7. Case 3. At 6 months' follow-up, a fully
regenerated nail and nail bed without nail bed graft.
with a concave or flat nail, the regenerated nail was noted
to assume the convexity of the nail splint due to its
moulding effect on the regenerating nail bed. There were
no infections in any of the case studied.
Although the standard of care for acute avulsion
injuries of the nail bed is split thickness nail bed graft,
this study demonstrates that the avulsed nail bed has its
own inherent regenerative potential. Hence, the intervention with split thickness nail bed graft is not
FIGURE 9. Case 10. At 7 months' follow-up, the nail is
fully regenerated.
necessary as long as the nail bed is adequately
protected. It seems that effective coverage of the nail
bed prevents desiccation and protects the clot and its
culture milieu conducive to spontaneous regeneration
of the nail bed and nail (Figs. 8 and 9). In all the cases,
the matrix was not avulsed except for case 9 (Fig. 1),
where at least 50% of its substance was avulsed on the
ulnar side.
1. Flatt AE. Nail bed injuries. Br J Plast Surg. 1955;8:34 -37 .
2. McCash CR. Free nail grafting. Br. J Plast Surg. 1955;8;
19 -33.
3. Saito H, Suzuki Y, Fujino K, et al. Free nail bed graft for
treatment of nail bed injuries of the hand. J Hand Surg.
1983;8: 171 -178.
4. Sheppard GH. Treatment of nail bed avulsions with split
thickness nail bed grafts. J Hand Surg. 1983;8:49 -54.
5. Ogo K. Does the nail bed really regenerate? Plast Reconstr
Surg. 1987:80:445 -447 .
6. Green D, Hotchkiss N, Pederson W, Wolfe S. Green's
Operative Hand Surgery, 5th edition. Philadelphia, PA:
Churchill Livingstone, 2005 :395 -396.
FIGURE 9. Case 9. At 9 months' follow-up, the nail is
fully regenerated. The patient is seen with another injury.
138
7. Ogunro 0. External fixation of the injured nail bed with the
INRO surgical nail splint. J Hand Surg. 1989 ;14A:236 -241.
Techniques in Hand and Upper Extremity Surgery