The general principles for treating all open fractures apply. As the majority of these injuries are due to crushing, edema of the soft tissues is most likely to develop and primary closure of any associated skin lacerations is not advisable.
2. Patient positioning
The patient is placed supine on a radiolucent table. A well-padded bump is placed under the ankle and heel of the surgical foot to elevate the foot for improved access and stabilize against rotation.
The nonoperative leg is secured with safety straps or taping.
To correct for external rotation of the leg and foot, a well-padded bump may be placed under the ipsilateral hip (a).
Alternatively, to correct for internal rotation of the leg and foot, a well-padded bump is placed under the contralateral hip (b).
3. Release of subungual hematoma
Closed crush injuries are often accompanied by subungual hematoma which can be exceedingly painful due to the pressure within the closed space. The hematoma can be easily released by perforating the nail bed with a red-hot needle, or paperclip. If no further treatment is indicated, the foot should be fixed in a cam walker to avoid any strain due to motion of the long flexor and extensor tendons.
4. Open reduction
In cases of open fracture, clear the fracture site of blood clot and debris. Use a dental pick to reduce carefully any displaced fracture fragments.
5. Repair of the nail bed
It is necessary to repair precisely the nail bed or the germinal zone because otherwise permanent deformity of the nail growth will result. These procedures are difficult to perform successfully without the help of magnifying loupes. An operating microscope is a good choice.
Use separate stitches and use 8.0 absorbable suture material.
Pitfall: Eversion or inversion of nail bed edges
Be careful while suturing the edges of the nail bed. Avoid eversion or inversion to prevent the permanent deformity of nail growth.
6. Reinsertion of the nail
Now reinsert the nail. There are 4 main reasons for nail reinsertion: 1) to prevent scarring between the eponychium and the nail matrix 2) to stabilize the fracture 3) the nail acts a biological barrier and protection 4) it acts as a template for the growth of a new nail
Dislocation of the nail
In some patients, the sinus is injured in such a way that it cannot retain the nail plate in position and the nail plate is gently drawn into the sinus using a suture. Use a 5 (0) nonresorbable nylon suture. Begin on the dorsal aspect proximal to the sinus and insert the needle so that it exits the sinus distal to the eponychium. Pass the needle through one side of the proximal edge of the nail plate. Then pass the needle back through the other side of the nail plate and then through the sinus of the nail so that it exits parallel to the first pass of the stitch. The sutures should be separated from one another by approximately 5 mm.
Apply gentle traction on the sutures. This will draw the nail plate back into the sinus. Once the nail plate is securely in its bed, tie the suture over a cotton or foam ball to prevent pressure injury to the skin.
Secure distal nail tip
After reinsertion, the nail has a tendency to tilt upwards distally.
To prevent this suture the distal nail tip to the nail bed with 2 or 3 interrupted sutures.
In case of nail loss the bed of the nail must be preserved for the growth of the new nail. The nail bed is protected by the application of a temporary orthosis made from polyethylen.
The polyethylen is tailored to the size of the nail...
...and then securely fixed with sutures to protect the nail bed.