Nailed It: Management of Nail Bed Injuries
Written by: Joel Aguilar, MD; Edited by: Timothy Khowong, MD, MSed
Background:
In the realm of hand injuries, one disputed area of discussion revolves around nail bed injuries. The nail bed is the tissue beneath the nail plate, it contains plenty of nerves and blood vessels, and it plays a crucial role in nail growth and function. When the nail bed becomes injured it could compromise its function, affect the cosmetic outcome of the nail, and potentially be complicated by infection. The severity of these injuries varies widely, ranging from minor lacerations to complete loss of the nail bed tissue. Consequently, the approach to treatment can differ significantly based on the extent and nature of the injury.
Some argue that removing the nail, repairing the underlying injury can restore nail function, improve cosmesis and prevent complications. On the other hand, opponents of repair debate that the procedure may be technically challenging due to the delicate nature of the tissue and may carry risks of infection or poor wound healing. Some advocate for naturally healing especially in minor injuries where conservative management might suffice. And finally, whether repairing the nail bed always results in superior long-term outcomes compared to conservative management is yet to be proven.
The Study:
The NINJA trial, a large multicenter RCT, examined whether replacing the nail after nail bed injury in children offers any benefit. The study found no difference in infection rates or cosmetic outcomes between replacing the nail and discarding it, showing no advantage to replacing the nail after repair. However, the study didn’t answer the more important question of whether repairing nail bed injuries is necessary at all.
Could it be possible that many nail bed injuries don’t need intervention and could simply be managed with conservative therapy? There is still yet to be concrete evidence that outcomes are similar without sutures or repair. Alternatively, some studies have shown that skin adhesive for nail bed injuries where the nail is already off is effective and less invasive. Overall, this study offers some support to the conservative approach but has not fully changed the culture and practice of avoiding unnecessary nail bed repairs.
References:
Jain A, Greig AVH, Jones A, et al. Effectiveness of nail bed repair in children with or without replacing the fingernail: NINJA multicentre randomized clinical trial. Br J Surg. 2023;110(4):432-438. doi:10.1093/bjs/znad031