Nail Base Needs Close Attention in Car Door Injury


STANFORD, CALIF. — Think of tuft fractures, which commonly occur when a child's finger is crushed in a car door, like toe fractures, advised Dr. Bernard W. Dannenberg at a recent pediatric update sponsored by Stanford University.

"You can get an x-ray, but we're not going to do anything … about them," said Dr. Dannenberg, director of pediatric emergency medicine at the Stanford (Calif.) University.

Dr. Dannenberg tells patients with tuft fractures or toe fractures the same thing. "If it still hurts in a week or 2, it's probably fractured. If it doesn't hurt, it was contused."

He nonetheless advises physicians to examine car door injuries closely, because an injury at the base of the nail bed needs to be surgically repaired, often under sedation, to prevent scarring or a deformity when the new nail grows out.

Such an injury should be loosely dressed, and an emergency medicine specialist or hand surgeon should see the patient within 12 hours or so, he said.

"Look very closely when you see them. [An avulsed nail base] just doesn't look like much," he said. "I've seen cases where the [physician] says, don't worry, the nail will fall off."

Fingertip amputations should be cleaned and debrided. If fingertip bones are exposed, they should be covered by closing the wound, if possible. In some cases, the bones may need to be rongeured down to permit wound closure over them. The tissue generally will not regenerate; however, Dr. Dannenberg said that the cosmetic and functional outcome often is excellent. "The skin heals wonderfully, and for the most part, you can't even see any difference."

Complete fingertip amputations can be reattached, although they are likely to necrose. "It probably will fall off, but it gives it some protection," he said.

In cases in which the skin cannot be closed around the injury, it can heal by secondary intention, so long as bone is not exposed, he said.

Subungual hematomas can be very painful, and a simple procedure can provide relief, explained Dr. Dannenberg. "All you have to do is take an 18-gauge needle and use it as a drill … [until] you see a drop of blood."

Both patients and parents should be distracted, since the procedure looks worse than it actually is, he said. Meanwhile, making tiny holes into two or three areas of the hematoma can provide "tremendous pain relief."

Dr. Dannenberg generally uses long-acting lidocaine to perform any necessary repairs of the finger after a car door crush injury. This provides 4–8 hours of pain relief until parents can fill a prescription for an analgesic such as Lortab, liquid hydrocodone, and acetaminophen.

This patient has an avulsed nail and lacerated nail bed with soft tissue loss.

In this photo, the patient's nail bed has been repaired and the nail reinserted. Photos courtesy Dr. Bernard W. Dannenberg

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