Toe Nail Injuries

The toe nail is susceptible to trauma in so many ways. In this article let's talk a bit about what happens in cases of trauma to the nail. We'll also talk about how to treat the nail following an injury.

The most common injury to the nail is a bruise beneath the nail called a subungual hematoma or runner's nail. The bruise (hematoma) forms beneath the nail (subungual) when the nail is compressed or avulsed (pulled away) from the underlying nail bed. More severe injuries to the nail include lacerations to the nail bed and crush injuries to the soft tissue and bone. Let's take a look at how to treat a nail injury.

Treatment of nail injuries

Be sure to wrap the injured toe with a clean (preferably sterile) bandage for 30-60 minutes following the injury. During this period of time, elevate the foot. This rest period will enable bleeding to subside.

Once bleeding has stopped, the next step is to evaluate the status of the nail plate. In most cases we recommend trying to keep the nail plate in place. If the nail is intact but bruising has formed beneath the nail, the fluid beneath the nail needs to be drained. Draining this fluid will relieve the swelling beneath the nail and significantly reduce pain.

Should you keep the injured nail in place? There's several pro's and con's to this decision, but most importantly, the damaged nail may be rejected by the surrounding soft tissue. This process takes a number of days. In most cases, we recommend trying to leave the nail in place and soak the foot to try and remove any loose debris under or surrounding the nail that was the result of the injury. When the nail can be preserved, the injured nail will act as a guide for the new nail as it grows in. When the old nail is removed, the soft tissue on the tip of the finger or toe will contract making it difficult for the new nail to reattach to the nail bed. We recommend that you follow these directions;

• If the nail is attached and a subungual hematoma is present, drain the subungual hematoma using the fine drill in The Nail Injury Repair Kit for Runner's Nail.

• In cases of subungual hematoma or partial nail avulsion, soak the injured nail twice a day in a Pedi-Boro soak or Epsom Salts following the directions on the box.

• If the nail is partially avulsed, secure the nail in place with a Nail Injury Repair Kit for Partial Nail Avulsions.

• Monitor the injured nail for redness, swelling or signs of infection. If you suspect an infection, please call you doctor for an antibiotic and possible removal of a portion of the damaged nail.

Long term management of the nail requires a little patience and a lot of compliance. The most important long term consideration isn't the prevention of soft tissue bacterial infection. What's most important is treating the nail to prevent a fungal infection. 7-10 days post injury, the tissue surrounding the nail becomes much less susceptible to bacterial infections. Continued use of antibiotics, will in many cases actually contribute to problems. The image at left shows a super infection of the skin adjacent to the nail resulting from the over-use of a topical antibiotic. And what's so striking in this image is the fact that the remaining portion of the nail is significantly infiltrated with a fungal infection. The lesson here is that once the potential for bacterial infection is resolved, shift gears and begin treating the nail for a fungal infection. Remember, all fugal infections of the nail begin with an injury to the nail. Therefore, all nail injuries should be treated with a topical antifungal medication to prevent the onset of a fungal infection.

Prior to an injury, the nail acts as a barrier and is able to fend off fungal infections. Following an injury to the nail, the door of susceptibility swings open allowing the fungus to infiltrate the nail. It's important to apply an antifungal medication (Tineacide, Elon Dual Defense, ClearZal) to the nail for the entire length of time it takes the new nail to grow out. This length of time can vary but is typically 3-4 months for fingernails and up to 10 months for toenails.

Proper application of an antifungal medication requires compliance. Fungus doesn't take a day off and neither should you. All it takes is a very small amount of topical antifungal applied twice a day. For more information regarding nail fungus, please review our article on onychomycosis.

Anonychia - congenital absence of nails

Beau's Lines - local or global disturbances of the nail matrix result in longitudinal changes to the nail

Cherry red nails - often the result of carbon monoxide poisoning

Clubbing of the nail - thickening of the distal aspect of the fingers due to cystic fibrosis, chronic ulcerative colitis, chronic hepatitis or subacute bacterial endocarditis

Eponychium - the fold of skin or site of attachment of the nail at the base overlying the matrix

Hyponychium - the fold of skin or site of attachment of the nail at the distal end of the nail where we would trim the nail

Keratin - cells that for many of the hard substances that grow on our bodies including hair and nail

Koilonychia - spoon shaped nails

Lunula - a white semi-circular area at the base of the nail

Mee's Lines - transverse line in the nail in patients who survive end stage liver disease

Melanotic Whitlow - dark changes of the distal nail and toe secondary to melanoma

Nail matrix - the pocket of cells that 'grow' the nail

Nail plate - the packed keratin cells that make up the nail

Onychochauxis - thick brittle nails

Onychogryphosis - thick deformed, claw like nails

Onycholysis - destruction of the nail due to impaired circulation or other circulatory compromise

Onychomycosis - thickening of the nail due to fungal infections

Pachonychia - large thick nails

Paronychia - incurvation with inflammation and pain along the entire edge of the nail.

Pincer nail - nails that are pinched in the center to tent up. Often result in ingrown nails.

Splinter hemorrhages - small blood clots beneath the nail. Suggestive of arterial disease, particularly atrial fibrillation

Subungual exostosis - bone spur of the distal phalanx, just beneath the nail plate

Subungual hematoma - bruising beneath the nail

Terry's Nail - Ivory white nails in patient's with end stage liver disease

Trumpet nail - see pincer nail

The nail grows from a small pocket of cells called the nail matrix. As each new generation of cells is formed, they push the previous generation of cells out along the nail bed toward the end of the finger or toe. As a result, the nail grows by being pushed out and off the nail bed.

There are several structures that make up the nail. The lunula is a white crescent shaped structure at the base of the nail. The lunula may be large or small, and in many cases even absent all together. The function of the lunula is unknown, but some have speculated that it represents the distal extension of the nail matrix.

The hyponychium (cuticle) is found at the base of the nail and creates a transition zone from the skin to the nail allowing the nail to slowly move away from the matrix to the distal tip of the nail. At that point, the attachment to the nail is referred to as the eponychium.

No information is available for this topic.

No information is available for this topic.

No information is available for this topic.

• Ingrown Toe Nail

• Onychomycosis

• Forefoot Pain

• Toe Nail Trimming

• Lister Corn

This article was written by Jeffrey A. Oster, DPM and last updated 2/8/13. No additional information is available for this topic.