Fingertip Injury & Nail Plate Management
The Dr. Czer Doctrine: PRESERVE THE PLATE
RETAIN THE NAIL (Default)
- Anatomic Splint: Excellent for stabilizing tuft fractures and other distal phalanx fractures.
- Eponychial Stent: Perfectly maintains the nail fold, preventing synechiae (critical!).
- Pain Reduction: Shields the exquisitely tender, exposed nail bed.
ELEVATE THE NAIL (Therapeutic)
- To Repair the Bed: The *only* reason. Indicated for any suspected complex laceration (see algorithm).
- Washout: For suspected open fractures (e.g., pediatric Seymour) to clean the bed and bone.
Decision Algorithm
START: Fingertip Injury
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Is there high suspicion of a nail bed laceration needing repair?
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Check for ANY of the following signs:
- Nail plate is traumatically avulsed or fragmented.
- Tuft fracture is present (this implies a bed laceration).
- Hematoma is >50% (in an adult).
- Hematoma is present in a pediatric patient (suspect Seymour Fx).
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YES to ANY sign above ↓
Protocol B: ELEVATE & REPAIR
(Elevate nail, repair bed, replace nail as stent)
NO to ALL signs above ↓
Protocol A: RETAIN
(Leave nail, trephinate if tense hematoma, repair skin only)
Technical Pearls: The RIGHT Way
1. ELEVATE, not Avulse
Use a blunt elevator. Start distally. Gently lift. Protect the germinal matrix.
2. Meticulous Bed Repair
Use fine absorbable suture. 5-0 chromic is standard for adults.
3. Stenting is MANDATORY
Replace original nail or use Xeroform. Consider 1 distal suture to seat the plate.