Hand pain: a chief complaint that can be seen at any level of emergency medicine. But do you know what to do if your patient has finger trauma involving the nail and happen to be in a place without a hand service to consult your troubles away? Say you see your patient who had a heavy object fall onto her digit earlier today. You see her nail split open, you see some blood, you don’t know if you see anything else. What do you do? Well, an appropriate exam would include not only an xray to evaluate for a fracture (everyone knows that) but also a good evaluation of the nail bed to evaluate for any nail bed lacerations. This involves removal of the entire nail, a procedure not often performed regularly and sometimes forgotten. Below is a wonderful step by step instruction on removal using a pair of sterile scissors easily found in every ED. A digital block is a must and a finger tourniquet will keep the site from bleeding as you perform the removal.

After any lacerations are cleaned and repaired the nail can be replaced as in the image. Or if the nail cannot be found or is too damaged this video has a wonderful technique of using the aluminum from a suture packet and shaping it into a false nail to protect the nail bed and keep the cuticle open for proper nail healing.

Bottom Line: Nail removal in setting of possible nail bed lacerations is an important ED procedure and should be done for proper evaluation and healing.

References:

Roberts, James R., et al. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. Elsevier, 2019.