The middle and distal third of the nail are the most frequent sites of injury. Fifty percent of injuries have an associated distal phalanx or tuft fracture. In general, the prognosis is worse with increasing tissue damage and with more proximal injuries. A finger x-ray may be indicated for extensive injuries to rule out a concomitant phalangeal fracture. This can be done with a heated paper clip or a handheld ophthalmic cautery.
Proper anesthesia is required.
This is best accomplished with a digital block or a metacarpal block. Once the nail plate is elevated, gentle distal traction on the nail plate will separate it from the proximal sulcus. However, there have been recent studies that indicate that even large subungal hematomas can be treated by simple trephination. No correlation was found between adverse outcome and the size of the subungal hematoma or the presence of a fracture. If you choose to repair the nailbed, the nail should be removed, and the lacerations should be repaired with 6-0 or smaller absorbable sutures.