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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 3  |  Issue : 1  |  Page : 19-21

Tackling nail injury in a primary care setting: A tricky turf


1 Department of Community Medicine, School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Dermatology, Venereology and Leprosy, Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India

Date of Submission20-Aug-2021
Date of Decision22-Sep-2021
Date of Acceptance22-Sep-2021
Date of Web Publication25-Feb-2022

Correspondence Address:
Nikita Sharma
Department of Community Medicine, School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jssrp.jssrp_19_21

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  Abstract 


Toenails provide stability to the foot. A stubbed toe may result in nail injury or fracture. Toe injuries are often ignored, leading to inappropriate or delayed management. The COVID-19 pandemic has badly affected the health services leading to further delay in treatment. We present a case report of an adult male who presented with an injured toe at a primary care clinic in India. Due to the apprehension of contracting severe acute respiratory syndrome coronavirus 2 infection and lockdown restrictions, the patient neither wanted to go to a higher center or get investigations done. The case report discusses the management and ways to handle such cases for primary care doctors in a resource-constrained setting.

Keywords: Nail trauma, toenail injury, toenail repair


How to cite this article:
Sharma N, Kumar M, Vashist S. Tackling nail injury in a primary care setting: A tricky turf. J Surg Spec Rural Pract 2022;3:19-21

How to cite this URL:
Sharma N, Kumar M, Vashist S. Tackling nail injury in a primary care setting: A tricky turf. J Surg Spec Rural Pract [serial online] 2022 [cited 2022 May 22];3:19-21. Available from: https://jssrp.org/text.asp?2022/3/1/19/338531




  Introduction Top


The nail is an important sensory organ that protects the tip of the digits. A nail unit comprises of nail matrix that produces a laminated keratinized nail plate that sits on the nail bed embedded within the nail folds.[1] The paronychium protects the lateral edges of the nail from infection. The eponychium and cuticle along with the nail plate seal the germinal matrix. Toenails grow slower than fingernails. Male toenails (1.65 mm) are thicker than females (1.4 mm). The injury to toenails does not garner as much attention as the fingernails. These patients usually present in a primary care clinic with limited resources. Such injuries may appear insignificant but may be accompanied by fracture of the hallux, ligament tear, and vascular injury.[1] There is not much difference in the management of nail injury of fingers and toes. However, there is a dilemma among doctors whether to replace the nail plate or remove it after repairing the nail bed. The lack of appropriate management can lead to pain, deformity, dystrophy, onychocryptosis, retronychia, and permanent loss of the nail. Primary care physicians must intervene early to prevent any loss of function and deformity. We discuss the management of a case of toenail injury presenting to a primary care clinic during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic.


  Case Report Top


A 28-year-old male present to the outpatient department (OPD) with an injured left foot after falling on the ground. The nail plate of the great toe was partially avulsed exposing the nail bed [Figure 1]. The injury to eponychium and paronychium was minimal. The movement at the distal interphalangeal joint was limited due to pain. There was no history of hypertension, diabetes, tuberculosis, drug allergy with a history of occasional alcohol use and smoking. The patient was advised an X-ray foot at a higher center to rule out any fracture. However, the patient refused to go for investigations due to his apprehension of contracting SARS-CoV-2 infection. All the patients presenting to secondary or tertiary care institutions in India had to undergo a rapid antigen test or RTPCR test for SARS-CoV-2. The patient was not ready to take the test and insisted on nail removal.
Figure 1: Partially avulsed nail plate of the left great toe showing the anatomical structures (a), the healed digit with the replaced nail two weeks postrepair (b)

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He was counseled, and the prognosis was explained. After examination, the patient was given a tetanus toxoid injection. The injured area was cleaned using normal saline, and part was prepared with povidone-iodine. About 3 ml of lignocaine (2%) was injected into the pulp and paronychium to relieve pain. The nail plate was removed and cleaned thoroughly. Any attachments were removed and spurs on both sides were trimmed. The nail plate was dipped in an antiseptic solution. The nail bed was irrigated with normal saline, and eponychium was approximated. The nail plate was placed over the nail bed and reinserted into the eponychial fold of the toe. Dressing in povidone-iodine soaked gauze was applied. The patient was prescribed oral antibiotics (amoxicillin 500 mg bid) and analgesics (diclofenac 50 mg bid) for 5 days. He was advised to avoid strenuous activity and return for wound dressing every alternate day.

On follow-up, the patient came to the OPD for dressing twice. He removed the bandage after 6 days on his own. After 2 weeks, a teleconsultation was done and the wound was completely healed [Figure 2]. The European quality of life five dimensions (EQ-5D-5L) descriptive system score was 11,121, and visual analog scale (VAS) was 95.[2] The replaced nail got detached after 4 weeks. The nail bed was healed with a normal nail plate growing underneath.


  Discussion Top


The treatment of nail bed injuries depends on multiple factors namely type of injuries (open/closed), loss of nail bed, fracture of the bone, etc.[3] Closed injuries with or without small subungual hematoma are conservatively managed. Any hematoma covering over 50% of the surface area of the nail requires evacuation by drilling holes or trephination. Laceration or avulsion of nail bed and damage to eponychial skin requires assessment of the extent of the injury. Usually, the nail plate needs to be removed to assess and treat the specific type of injury. The X-ray of the injured finger will rule out any fracture. A point of care ultrasound is a new modality that may detect nailbed injury or phalanx fracture under the subungual hematoma.[4] Roughly, half of the nail bed injuries may have tuft fracture or extraphyseal fracture. After removal of the nail plate, repair of nail bed laceration is done with absorbable sutures that help in maintaining fracture reduction. A displaced extraphyseal fracture can be fixed with K wires and covered with the replaced nail plate or Zimmer splint. The ongoing NINJA trial may provide an evidence-based solution to whether to replace the nail plate or remove it.[5] Using an old nail as a splint has a small risk of infection.[6] Chloramphenicol ointment has been used as an adhesive for the nail plate and may provide anti-bacterial benefits.[7] Medical adhesives such as 2-octyl cyanoacrylate and histoacryl-nbutyl-2-cyanoacrylate are effective nail plate adhesive among children.[8] Angular phenolization helps to prevent the ingrowing toenail.[9] Applying liquid phenol (80%) on the cavity of eponychium may prevent spur formation.

This case proposes an alternate way to treat nail injuries in a resource-poor setting. We did not use sutures or any adhesive to fix the nail plate to the nail bed. It may help when either the sutures or adhesives are not available or nonaffordable to the patient. The advantage includes easy removal of the replaced nail plate in case of infection or fracture of underlying bones. The replaced nail protected the nail bed and aided in healing. One must adhere to antiseptic precautions and may give antibiotics to prevent any local infection. The EQ-5D-5L instrument helped to assess the health state of the patient in the recovery phase.


  Conclusion Top


Appropriate assessment, adequate management, and use of antibiotics in toenail injury can promote recovery and prevent deformity in a resource-constrained setting.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kamrani P, Pillarisetty LS. Anatomy, Bony Pelvis and Lower Limb, Toe Nails. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021.  Back to cited text no. 1
    
2.
EuroQol Research Foundation. EQ-5D-5L – EQ-5D 2021. Available from: https://euroqol.org/eq-5d-instruments/eq-5d-5l-about/. [Last accessed on 2021 Aug 18].  Back to cited text no. 2
    
3.
Bharathi RR, Bajantri B. Nail bed injuries and deformities of nail. Indian J Plast Surg 2011;44:197-202.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Gungor F, Akyol KC, Eken C, Kesapli M, Beydilli I, Akcimen M. The value of point-of-care ultrasound for detecting nail bed injury in ED. Am J Emerg Med 2016;34:1850-4.  Back to cited text no. 4
    
5.
Jain A, Jones A, Gardiner MD, Cooper C, Sierakowski A, Dritsaki M, et al. NINJA trial: Should the nail plate be replaced or discarded after nail bed repair in children? Protocol for a multicentre randomised control trial. BMJ Open 2019;9:e031552.  Back to cited text no. 5
    
6.
Nanninga GL, de Leur K, van den Boom AL, de Vries MR, van Ginhoven TM. Case report of nail bed injury after blunt trauma; what lies beneath the nail? Int J Surg Case Rep 2015;15:133.  Back to cited text no. 6
    
7.
Pasapula C, Strick M. The use of chloramphenicol ointment as an adhesive for replacement of the nail plate after simple nail bed repairs. J Hand Surg Am 2004;29:634-5.  Back to cited text no. 7
    
8.
Edwards S, Parkinson L. Is fixing pediatric nail bed injuries with medical adhesives as effective as suturing? A review of the literature. Pediatr Emerg Care 2019;35:75-7.  Back to cited text no. 8
    
9.
Eekhof JA, Van Wijk B, Knuistingh Neven A, van der Wouden JC. Interventions for ingrowing toenails. Cochrane Database Syst Rev. 2012;(4):CD001541. doi: 10.1002/14651858.CD001541.pub3.  Back to cited text no. 9
    


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