Nail bed injuries
Learning outcomes
• Understand the relationship between anatomy , functions and
injuries of the nail bed
• Develop repair ...
Nail bed lacerations
• Remove nail and inspect nail bed
• Nail fold may be elevated using back
cuts at the corners
• Simpl...
Anatomy of the nail complex
Macroanatomy
Production of the nail
• Onchyn – keratinous material
produced by the death of the
germinal cells
• Nail growth slows afte...
Nail vascular supply
• From volar digital arteries
• Large branch to the pulp
• Branch to the paronychium
• Branch to the ...
Types of Nail Injuries
• Crush injuries
• Sharp laceratons
• likely to result in tip
amputations
• Avulsion
• Iatrogenic
•...
Basic principles
• Injuries may involve several anatomic structures
• Loss of germinal matrix results in no hard nail grow...
Paronychial injuries
• Simple lacerations – repaired primarily
• Loss of part of the paronychium
• VY advancement
• Cross-...
Associated DP fractures
• 50% of nail bed injuries
• Comminuted tuft fractures
• Can be stabilised by the avulsed nail wit...
Subungual Haematoma
• If nail plate still adherent –
trephinization
• Using cautery
• Heated paper clip
• Needle
• Nail be...
Complex lacerations
• Accurate determination of the
damaged tissues
• Replace like with like
• Complex stellate laceration...
Avulsions
• Look under avulsed nail
• In small avulsions replace nail
• Loss of sterile matrix
• Graft from adjacent steri...
Loss of germinal matrix
• Graft of 1cm can take
• Delayed to determine
viability of nail
• Composite graft from
toe/finger...
Partial amputations
• Ablate nail bed completely
• Cover the tip
• Shorten the nail bed
• Hook nail - Unsightly and interf...
Eponychial loss
• After trauma and tumour
resection
• Any excision should be replaced
with a composite graft
• Reconstruct...
Onycholysis
• Non-adherence
• Caused
• Trauma
• Irritation
• Dissolving of hyponychial plug
• Age
• Onychomychosis
• Scarr...
Split nails
• Longitudinal scar
• Removal of nail
• Narrow, diagonal or transverse –
excision and suturing
• Longitudinal ...
Bone irregularities
• Osteophytes
• Post traumatic inclusion cysts of
sterile matrix
• Deformity of nail and erosion of
bo...
Nail absence
• Congenital or traumatic
• Skin graft
• Artificial nail
• Microvascular transfer
• Non-vascularised composit...
Tech Hand Up Extrem Surg. 2005 Mar;9(1):42-6.
The aesthetic mini wrap-around technique for thumb reconstruction.
Adani R1,...
Pincer nail
• Thumb and great toe
• Pain
• Trauma, tight shoes, hereditary
• Nail bed becomes neuro-
vascularly compromise...
Hooked nail
• Growing nail follows nail matrix
• Tight closure of finger tip amputation
• Loss of bony support
• Absent di...
Antenna procedure
J Hand Surg Am. 1983 Jan;8(1):55-8.
The "antenna" procedure for the "hook-nail" deformity.
Atasoy E, God...
Br J Plast Surg. 1992 Nov-Dec;45(8):591-4.
Trimmed second toetip transfer for reconstruction of claw nail deformity of the...
DonorRecipient
 Nail bed injuries
 Nail bed injuries
 Nail bed injuries
 Nail bed injuries
 Nail bed injuries
 Nail bed injuries
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Nail bed injuries

Understand the relationship between anatomy , functions and injuries of the nail bed Develop repair and reconstruction techniques for the injuries and their complications
Published on: Mar 3, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - Nail bed injuries

  • 1. Nail bed injuries
  • 2. Learning outcomes • Understand the relationship between anatomy , functions and injuries of the nail bed • Develop repair and reconstruction techniques for the injuries and their complications
  • 3. Nail bed lacerations • Remove nail and inspect nail bed • Nail fold may be elevated using back cuts at the corners • Simple laceration – 7/0 chromic sutures • Repair under magnification • Limit debridement – avoids tension on repair and prevent scarring • Replace nail plate or cover with artificial sheet – protects and moulds nail bed
  • 4. Anatomy of the nail complex Macroanatomy
  • 5. Production of the nail • Onchyn – keratinous material produced by the death of the germinal cells • Nail growth slows after the age of 30 years • Produced in 3 areas • Germinal matrix – 90% • Sterile matrix – adherence • Dorsal roof – nail shine
  • 6. Nail vascular supply • From volar digital arteries • Large branch to the pulp • Branch to the paronychium • Branch to the proximal nail fold • Multiple small branches into the nail bed • Radial vessels are larger on the ring and small finger. • Venous return is in a random fashion over dorsum
  • 7. Types of Nail Injuries • Crush injuries • Sharp laceratons • likely to result in tip amputations • Avulsion • Iatrogenic • Inadequate phalangeal reduction • Placement of fixation pins • Nail biting/ flicking of the eponychium
  • 8. Basic principles • Injuries may involve several anatomic structures • Loss of germinal matrix results in no hard nail growing • Loss of sterile matrix results in non-adherence • Radiographs to evaluate assoc. fractures
  • 9. Paronychial injuries • Simple lacerations – repaired primarily • Loss of part of the paronychium • VY advancement • Cross-finger flap • Thenar flap • Dorsal roof laceration • Primary suture • Loss of tissue – grafting needed
  • 10. Associated DP fractures • 50% of nail bed injuries • Comminuted tuft fractures • Can be stabilised by the avulsed nail with figure of eight suture • Proximal DP # result in nail deformities • Adequate reduction with crossed K- wires • Salter I of the DP can present as avulsed nail sitting on the eponychium – accurate reduction needed
  • 11. Subungual Haematoma • If nail plate still adherent – trephinization • Using cautery • Heated paper clip • Needle • Nail bed injuries may be missed • Partially avulsed nail plate • Remove and inspect • Leave in place
  • 12. Complex lacerations • Accurate determination of the damaged tissues • Replace like with like • Complex stellate lacerations • Meticulous re-apposition • Inspect under surface of nail plate
  • 13. Avulsions • Look under avulsed nail • In small avulsions replace nail • Loss of sterile matrix • Graft from adjacent sterile matrix • Loss of >50%- graft from toe/adjacent finger
  • 14. Loss of germinal matrix • Graft of 1cm can take • Delayed to determine viability of nail • Composite graft from toe/finger • Acutely – less scar tissue and better blood supply but more risk of infection
  • 15. Partial amputations • Ablate nail bed completely • Cover the tip • Shorten the nail bed • Hook nail - Unsightly and interferes with function • Loss of nail bed but reasonable bony support – combination of local flap and nail bed graft
  • 16. Eponychial loss • After trauma and tumour resection • Any excision should be replaced with a composite graft • Reconstructing the dorsal roof of the nail • split-thickness sterile matrix graft on the deep surface of the local flap
  • 17. Onycholysis • Non-adherence • Caused • Trauma • Irritation • Dissolving of hyponychial plug • Age • Onychomychosis • Scarring in the sterile matrix • Narrow – excised and primary sutured • Wide - grafted
  • 18. Split nails • Longitudinal scar • Removal of nail • Narrow, diagonal or transverse – excision and suturing • Longitudinal – multiple z-plasties • Wide • Split thickness sterile matrix graft • Full thickness germinal matrix graft • Split thickness graft of germinal matrix do not produce nail • Horizontal scar – double nail
  • 19. Bone irregularities • Osteophytes • Post traumatic inclusion cysts of sterile matrix • Deformity of nail and erosion of bone • Curettage of cysts • Enchondromas • Curettage and bone graft • Fish-mouth incision
  • 20. Nail absence • Congenital or traumatic • Skin graft • Artificial nail • Microvascular transfer • Non-vascularised composite graft • less reliable • better results in children
  • 21. Tech Hand Up Extrem Surg. 2005 Mar;9(1):42-6. The aesthetic mini wrap-around technique for thumb reconstruction. Adani R1, Marcoccio I, Tarallo L, Fregni U.
  • 22. Pincer nail • Thumb and great toe • Pain • Trauma, tight shoes, hereditary • Nail bed becomes neuro- vascularly compromised • Nail removal • Excision of paronychium • Freeing paronychium from periosteum
  • 23. Hooked nail • Growing nail follows nail matrix • Tight closure of finger tip amputation • Loss of bony support • Absent distal phalanx • Trim nail bed • Replace bone • Shorten nail • Release pulled over nail bed – V-Y • Bone graft
  • 24. Antenna procedure J Hand Surg Am. 1983 Jan;8(1):55-8. The "antenna" procedure for the "hook-nail" deformity. Atasoy E, Godfrey A, Kalisman M.
  • 25. Br J Plast Surg. 1992 Nov-Dec;45(8):591-4. Trimmed second toetip transfer for reconstruction of claw nail deformity of the fingers. Koshima I1, Moriguchi T, Umeda N, Yamada A.
  • 26. DonorRecipient

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