The replaced nail acts as a splint or mold to maintain the fold for new nail growth and to protect the fingertip. Severe stellate lacerations and nailbed avulsion injuries carry a poor prognosis. It is important to return all fragments of the nailbed as accurately as possible. Often, a fragment of the nailbed is attached to the undersurface of the avulsed nail. If it is small, the nail and the nailbed may have to be replaced without separating them.
Surgical referral is suggested for severe crush injuries and nailbed avulsions.
Occasionally, grafting is necessary. A drainage hole should be placed in the nail prior to replacement. The nail should be sutured in place with 6-0 sutures for 3 wk. A hand surgeon should be consulted for severe injuries. In general, except for a simple subungual hematoma, a wound check in 3-5 d is suggested to check for infection and to repack the nail fold, if necessary.