Nailbed injuries may be difficult to identify and there is no consensus on repair technique.
Identifying Nailbed Injury
Not all nail bed lacerations are obvious. Even if the nail is intact, a subungual hematoma is greater than 50% of the nail bed, or an associated distal phalanx fracture may suggest one is present.
Removing the Nail
Not every nailbed laceration requires nail removal and repair. If the nail is firmly adherent and disruption of surrounding tissue is minimal, there is likely to be a good cosmetic outcome without primary nail bed repair. However, it may be prudent to at least trephinate the subungual hematoma.
Optimizing Nail Regeneration
If the nail is removed (or the proximal nail fold is avulsed during the injury) it is generally accepted that the eponychial fold should be stented in order to prevent the base of the nail and the eponychial fold from scarring to the nail fold during healing. If this occurs, it can result in failure of nail regrowth.
Technique
Remove the nail and identify the nailbed laceration
Repair with simple interrupted, 6-0 size absorbable suture
Cut directly over the knot
Create eponychial fold stent fashioned into the shape of a nail using inert material (xeroform, original nail, or aluminum from suture package)
Secure with non-absorbable suture between paronychial fold and stent (starting on skin side). Other options for securing the stent include dermal adhesive.