Eur J Plast Surg (1998) 21:106±107
R. Alvi ´ S. Jones ´ W. Jaffe ´ A.J. Howcroft
Long-term sequel of nail bed trauma
Received: 5 November 1996 / Accepted: 8 May 1997
R. Alvi (
) ´ S. Jones ´ W. Jaffe ´ A.J. Howcroft
Department of Plastic and Reconstructive Surgery,
Royal Preston Hospital, Sharoe Green Lane North,
Fulwood, Preston, Lancashire PR2 9HT, UK
Tel. +44-1772-716-565; Fax +44-1772-710-547
Abstract We report the long term sequel of a finger tip
injury (case report). Attention to detail, particularly in re-
pairing the nail bed and a decision at the time to either re-
tain and repair, or excise fully, the germinal matrix could
avoid long term complications.
Key words Fingertip injury ´ Nail bed ´ Complications
Finger injuries involving the nail, nail bed and germinal
matrix are not an uncommon occurrence. Of all trauma
of the fingertip, between 13.8%  ±15%  of cases
have various degrees of nail bed avulsion.
The long-term sequel of digital injuries involving the
nail, nail bed and root includes abnormalities of nail
growth  which may cause functional impairment, be
cosmetically unacceptable or cause great discomfort.
Because of the high incidence of these deformities/ab-
normalities, it is important to diagnose and treat these ad-
equately in the first instance . We report a case of ab-
normal nail growth seven years after reconstruction of a
completely degloved thumb with a reversed radial fore-
Whilst working on a lathe machine, a 21-year old left-handed male
sustained a degloving injury with complete loss of skin and nail to
his non dominant thumb. Resurfacing of the thumb was undertaken
with a reversed radial forearm flap after adequate wound toilet (Fig.
1). Initial results were satisfactory with the patient returning to his
Seven years later he presented with a painful cystic swelling at the
tip of the reconstructed thumb (Fig. 2). This was fluctuant and tender.
In addition a sharp pointed object could be felt within the cyst.
X-ray demonstrated a crescentric calcified mass arising from the
dorsum of the distal phalanx (Fig. 3).
At operation the cyst was excised and found to contain viscous
fluid and an abnormal-looking nail (Fig. 4).
The remaining germinal matrix was also excised. He made an
Whilst it has been the standard practice to excise the ger-
minal matrix in cases where the nail bed cannot be ade-
quately reconstructed, we feel it is important to under-
stand the anatomy of the nail, nail bed and root and mode
of growth of the nail to surgically treat such injuries.
The nail is made up of cornified epithelial cells. The
deep surface is firmly adherent to its bed. The nail bed
has longitudinal fibres that anchor the dermis to the peri-
osteum of the distal phalanx .
Zaias  in his description of anatomy and growth
centres of the nail stated that the proximal nail fold served
only to shape the dorsal root with all the growth centres
located in the root (germinal matrix or lunula).
The germinal matrix is a plate of living epidermal cells
which is closely bound by fibrous tissue to the dorsum of
the terminal phalangeal bone  and is in close proximity
to the insertion of the extensor hood.
In injuries to digits, part or all of the nail root and
proximal nail fold are at risk of being destroyed or dis-
placed. It has been shown [3, 4, 6] that primary repair
achieves good functional and aesthetic results.
A finger nail will grow in the position or direction of
the nail root and bed. Hence if the matrix is displaced
and improperly aligned, the regenerating nail could end
up in an abnormal position. This has been demonstrated
by our patient.
The general principles of treatment should be meticu-
lous wound toilet with very minimal debridement of nail
root and bed with either accurate repair of the nail bed
with proper placement of the matrix, or total excision.