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    Nail Bed Injury

    Minor injuries can sometimes become a major detriment to the function of a member of a survival group. Although not as life-threatening as a gunshot wound or an open fracture, nail bed injuries are common; they will be more so when survivors are required to perform carpentry, chop wood, or other duties to which they’re not accustomed.

    Your fingernails and toenails are made up of protein and a tough substance called keratin. They are, as you might imagine, similar to the claws of animals. When we refer to issues involving nails, we refer to it as “ungual” (from the latin word for claw: unguis).

    NAIL ANATOMY

    The nail consists of several parts:

    The nail plate (body): this is the hard covering of the end of your finger or toe; what is generally considered to be the nail.

    The nail bed: The skin directly under the nail plate. Made up of an upper and lower layer (“epidermis” and “dermis”) just like the rest of your skin, the superficial epidermis moves along with the nail plate as it grows. Vertical grooves attach the superficial epidermis to the deep dermis. In older people, the nail plate thins out and you can see the grooves if you look closely. As with all skin, blood vessels and nerves run through the nail bed.

    The nail matrix: The portion or root at the base of the nail that produces new cells for the nail plate. You can see a portion of the matrix in the light half-moon (the “lunula”) visible at the base of the nail plate. This determines the shape and thickness of the nail; a curved matrix produces a curved nail, a flat one produces a flat nail.

    The cuticle: The thickened layer of skin surrounding fingernails and toenails. New, living cells in the cuticle are known as the “eponychium.”

    Nail Trauma

    The nail plate may be ripped off by some form of trauma. This is known as a “nail avulsion.” The nail may be partially or completely gone, or may just be lifted up off the nail bed. Ordinarily, depending on the type of trauma, an x-ray would be performed to rule out a fracture of the digit; you won’t have this tool available without modern facilities, but you may still need to intervene. You will:

    • Numb the area if local anesthesia is available.
    • Clean the nail bed thoroughly with saline solution, if available, and irrigate out any debris. Paint with Betadine (two percent povidone-iodine solution) or other antiseptic.
    • Cover the exposed (and very sensitive) nail bed with a non-adherent (Telfa) dressing. Some add petroleum jelly for additional protection. Change frequently. Avoid ordinary gauze, as it will stick tenaciously to the nail bed and be painful to remove.
    • If the nail plate is hanging on by a thread, remove it by separating it from the skin folds using a small surgical clamp. You can consider placing the avulsed nail plate on the nail bed as a protective covering; it is dead tissue, but may be the most comfortable option. Avoid scraping or clipping off loose edges, as it may affect the nail bed’s ability to heal.
    • If the nail bed is lacerated, suture it (once cleaned) with the thinnest absorbable suture available, such as 6-0 Vicryl PGA. Suture closure is described later in the book.
    • Place a dressing over the wound. It would be wise to immobilize the digit with a padded finger splint to protect it from further damage. Begin a course of antibiotics if the nail bed was contaminated with debris.
    Trephination (left) of Subungual hematoma

    In some crush injuries, such as striking the nail plate with a hammer, a bruise (also called an “ecchymosis”) or a collection of blood (a “hematoma”) may form underneath. A bruise will be painful, but the worst pain should subside within an hour or two. A hematoma, however, will continue to be painful even several hours after the event. A bruise will likely appear brownish or blue, but a hematoma may appear a deep blue-black.

    For a bruised nail, little needs to be done other than giving oral pain meds, such as Ibuprofen. For a significant hematoma, however, some suggest a further procedure called “trephination”. In this instance, a very fine drill (or a hot 18-gauge needle or paper clip) is used to make a hole in the nail plate. This opening must be large enough to allow the blood that has collected under the nail to escape. Once the pressure is relieved, the pain will abate.

    This procedure should not be performed unless absolutely necessary, as the pain will eventually decrease over time by itself. If you go too deep through the nail, you may further injure the nail bed. Make sure to keep the finger dry, splinted, and bandaged for a minimum of 48 hours afterwards.

    It’s important to realize that damage to the base of the nail (the matrix) may be difficult to completely repair, and that future nail growth may be deformed in some way. In situations where modern medical care is available, a hand surgeon is often called in to give the injury the best chance to heal appropriately. Even then, a higher incidence of issues, such as “ingrown” nails, may occur over time. A completely torn-off nail will take four to five months to grow back, maybe longer.

    INGROWN TOENAILS

    Ingrown toenail

    Ingrown toenails, also known as “onychocryptosis,” may not be considered a major issue; that is, until you have one.  When you have to be at full efficiency just to survive, you don’t want to be in pain every time you take a step. In the worst scenarios, ingrown nails can cause skin ulcers, blood infections (also called “septicemia”), or even total loss of circulation (“gangrene”).

    An ingrown toenail occurs when the edge of the nail grows downward into the skin of the toe. It can occur for a number of reasons, but poorly fitting shoes and poor trimming are the most common causes. Although any toenail can become ingrown, the big toe is usually involved.

    The skin along the edge of a toenail that is ingrown may appear:

    • Red
    • Swollen
    • Painful
    • Warm to the touch

    These are signs not only of pressure on the skin, but also, possibly, the beginning of an infection. If not treated, the condition worsens, possibly even leading to the drainage of pus.

    Shoes that are either too tight or too loose can cause ingrown toenails. If too loose, it causes continual pounding of your big toe against the inside due to movement within the shoe as you walk. With shoes that are too small for your foot, extra pressure is placed on your toes which prevents normal nail growth.

    Nails that are not trimmed properly can also cause ingrown toenails. This happens when your toenails are trimmed too short or you cut your toenails in a rounded fashion instead of straight across. Rounded cuts are appropriate for fingernails, but not toenails. The edges of the nails will tend to curl downward and grow right into the skin.

    While the above problems can be fixed, some less avoidable factors like heredity, injuries, or medical conditions may also cause ingrown toenails. Some people are born with nails that are curved and naturally tend to curve inward. Injuries to the nail bed can also cause ingrown toenails, especially if it affects the germinal matrix, the living part of the nail that produces new cells.

    People with diabetes or other illnesses that cause poor circulation are also at higher risk for these problems. A diabetic, for example, may experience nerve damage and not realize that excessive pressure is being applied to the toes by ill-fitting shoes. They may not even notice that the nail is growing into the skin.

    Of course, in normal times, medical specialists deal with the problem. Off the grid, however, here’s some tips on how to treat an ingrown nail:

    • Soak the foot in warm water with Epsom salts three to four times a day. In between soaks, keep the toe dry.
    • Use an antiseptic to decrease the bacterial count in the area.
    • Place a small piece of moist cotton, waxed dental floss, or other material under the ingrown edge to help it grow away from the skin.
    • Consider wearing sandals until improved.

    Aggressive Treatment

    At some point, the pain may be so great that the medic must intervene more aggressively. In these circumstances, you may have to remove the offending segment of nail.

    The procedure will involve the ingrown, curved side of the nail, about 1/5 or less of the nail plate width. A diagonal trim to remove the offending corner may alleviate the pain and pressure, but the medic may have to cut all the way down to the base of the nail plate in some cases. This procedure is more easily done with a digital block (discussed elsewhere) using numbing medicine such as lidocaine. Avoid lidocaine mixed with epinephrine, however; it may compromise the circulation and possibly lead to gangrene.

    After the procedure, soak the affected toe in warm water with Epsom salts or essential oil drops of tea tree, lemon grass, eucalyptus, rosemary, or citron. Dry and cover with a bandage or loosely rolled gauze.

    If the toe is infected, antibiotics might be appropriate. Over-the-counter antibiotic ointment may be helpful here as prevention, but oral antibiotics, such as cephalexin, amoxicillin, or clindamycin for several days may be necessary.  Antibiotics are discussed in their own section.

    If a portion of the nail is cut off, patience is required. It will take months for the nail to regrow. If your patient has a genetic tendency toward ingrown toenails, be prepared to deal with recurrences. Wearing properly-fitted and protective shoes, managing medical conditions, and teaching appropriate foot grooming methods will help.

    Joe Alton MD

    Dr. Joe Alton

    This article is an excerpt from our forthcoming 4th Edition of the Survival Medicine Handbook! More to follow, but for now, please support our mission to place a medically prepared person in every family by checking out our quality medical kits, individual supplies, and personal protection gear at store.doomandbloom.net. You’ll be glad you did.

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