An avulsion or crush injury may tear the nail completely away from the digit or raise a flap of nail bed matrix. Often fragments of matrix tissue may be left on the underside of the avulsed nail; these should be preserved for use as free grafts and, when possible, attached to the nail bed using fine 7-0 absorbable sutures. When the nail or avulsed nail bed fragments are not available, or in the case of a large defect, a full-thickness nail bed graft can be harvested from the patient's toe and sutured into the nail bed of the affected finger. As these injuries are complex and their repair is technically challenging, consultation with a hand or plastic surgeon is appropriate. In addition, avulsion injuries to the nail bed have the poorest prognosis of any fingertip injury.
Avulsion injuries may also incompletely tear the proximal portion of the nail bed or the germinal matrix, normally located under the eponychium. When this happens, the germinal matrix may lie on top of the eponychium. Management entails replacement of the matrix into its anatomic position using a series of three horizontal mattress sutures (Fig 39:3). One suture is placed through the center and one in each corner of the eponychial fold. The sutures are then passed through the proximal portion of the corresponding segment of avulsed germinal matrix and then back out through the nail fold, pulling the matrix back to its anatomic position. 8
FIG. 39-3. Technique for repair of an avulsion of the germinal matrix using three horizontal mattress sutures.(From Chudnofsky CR, Sebastian S: Special wounds—Nail bed, plantar puncture, and cartilage. Emerg Med Clinics North Am 10:808, 1992, with permission.)
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