With the ongoing growing trend of nail art, the nail size seem to be growing right along with it, and longer nails are at risk for getting caught and pulled off the nail bed. This can happen in a variety of scenarios from kids during rough play, adults doing hard labor, playing sports, falls, etc., anything that puts undue force onto the nail.
Let's orient us to the different parts of the nail:
We have been taught to replace avulsed nails into the eponychial fold after nail bed repair to act as a splint, reduce pain, and prevent adhesions with the goal of better cosmetic outcomes. However, the last time I had a patient with a toe nail avulsion, a podiatrist came down and told me that once the nail bed laceration is repaired that I could just wrap it with xeroform gauze without replacing the nail or using anything to stent open the nail bed. The podiatrist stated that it takes a long time, but the nail eventually grows back.
Let's set the scene with a case:
5 y/o female presents to the ED with an injury to their left 3rd digit after getting caught in a door while playing with her siblings. There is a nail avulsion from the nail bed with a laceration injuring the nail and nail bed. The patient has a linear laceration on the nailbed and the nail has been avulsed looking like this:
Xrays were done and there is no fracture. The patient requires ketamine for procedural sedation prior to a digital block, irrigation, and repairing the nail bed laceration. Before replacing the nail into the eponychial fold, the patient starts waking up. As you consider re-sedating the patient to replace the nail, you remember the NINJA Trial.
Evidence from NINJA Trial (2023):
A randomized controlled trial involving approximately 450 children compared outcomes between nail replacement and non-replacement after nail bed repair
Results showed no significant difference in infection rates at 7 days or cosmetic outcomes at 4 months between the two groups
Secondary outcomes, including pain, patient satisfaction, and delayed infections, also showed no significant differences
Healthcare costs were higher in the nail replacement group
Implications:
Replacing the nail may not be necessary for satisfactory cosmetic outcomes in pediatric patients
If nail replacement is straightforward, it can be performed; however, if challenging, it is acceptable to omit this step
Considerations for Subungual Hematomas:
Traditional teaching recommends nail removal for hematomas covering more than 50% of the nail
Current evidence supports conservative management, such as trephination for drainage, without nail removal
Takeaways:
Nail replacement after avulsion is not critical for nail regrowth or cosmetic outcomes in children
Trephination for drainage of subungal hematomas