Fingertip and nailbed injuries

1. High-Yield Summary

• Pervasive Upper Extremity Trauma: Fingertip and perionychial trauma represents the most common injury to the hand encountered in emergency and orthopaedic practice, with high-frequency bimodal peaks in young pediatric populations (crush in door frames) and working-age industrial adults.
• Critical Perionychial Differentiation: The nail unit comprises the germinal matrix (proximal, producing 90% of nail plate volume via gradient parakeratosis) and the sterile matrix (distal, providing adherence via onychocytes). Disruption of the germinal matrix causes split or dystrophic nail plates, while sterile matrix loss leads to non-adherent nail deformities.
• Pediatric Red Flag (Seymour Fracture): A crush injury with an open proximal nail plate avulsion in a pediatric patient is a Salter-Harris I or II fracture-dislocation of the distal phalanx with entrapped germinal matrix—an open fracture equivalent demanding operative debridement, anatomical reduction, and antibiotic coverage to prevent growth arrest and osteomyelitis.
• Preservation Over Resection: Distal fingertip amputations without exposed cortical bone (Allen Type I and distal Type II) heal with superior sensory 2-point discrimination (3–5 mm) and aesthetic contour under semi-occlusive dressings via secondary intention compared to primary stump revision.
• Modern Evidence-Based Synthesis: The landmark multicentre NINJA randomized controlled trial demonstrated that routine replacement of the native fingernail plate after nailbed repair does not reduce infection or improve late cosmetic appearance, while randomized data confirms 2-octylcyanoacrylate adhesive achieves equivalent functional cosmesis with marked reduction in procedural duration.

2. Anatomy

The fingertip is functionally defined as the portion of the digit distal to the insertions of the flexor digitorum profundus (FDP) and terminal extensor tendons onto the base of the distal phalanx. This specialized biomechanical organ provides fine discriminative sensory feedback, tactile grip stability, and dorsal counter-pressure against the nail plate.

The Perionychium (Nail Complex)

• Nail Plate: Hard, cornified keratinized epithelial sheet originating from the germinal matrix and growing distally over the sterile matrix at an average rate of 0.1 mm/day (3–6 months for complete regeneration).
• Germinal Matrix: Lies on the dorsal periosteum of the distal phalanx base, extending from 5 to 7 mm proximal to the eponychium (proximal nail fold) to the distal border of the lunula (the white crescentic zone). The germinal matrix is responsible for 90% of nail plate volume. Disruption or iatrogenic suture scarring here produces permanent nail division (split nail deformity).
• Sterile Matrix: Extends from the distal margin of the lunula to the hyponychium. It is lined with vascularized, ridged squamous epithelium that anchors the growing nail plate firmly to the periosteum of the distal phalanx. Injuries to the sterile matrix result in non-adherent nail segments or subungual pterygium.
• Eponychium and Proximal Nail Fold: The dorsal skin fold covering the germinal matrix. The dorsal roof of the nail fold produces the dorsal shiny surface layer of the nail, while the ventral floor forms the dorsal aspect of the germinal matrix. The cuticular seal prevents bacterial inoculation into the proximal cul-de-sac.
• Paronychium: The lateral epidermal folds bordering the nail margins. Disruption creates paronychial sinus tracts or chronic paronychia.
• Hyponychium: The specialized thickened junctional epithelium beneath the free distal edge of the nail plate, acting as the primary barrier preventing subungual contamination.

Pulp and Neurovascular Architecture

The volar digital pulp consists of fibrous vertical septa (retinacula cutis) extending from the periosteum of the distal phalanx to the reticular dermis, compartmentalizing specialized fatty lobules. This micro-architecture resists shearing forces during precision pinch and power grip. Cleland’s ligaments (dorsal to the digital neurovascular bundle) and Grayson’s ligaments (volar to the bundle) secure the cutaneous sleeve while safeguarding the digital vessels and nerves.

Paired proper digital arteries run along the lateral and medial margins of the digit deep to Grayson’s ligaments, forming a rich distal anastomotic vascular arcade across the base and tuft of the distal phalanx. Digital nerves divide into arborizing volar tactile branches with high Meissner and Merkel receptor densities, maintaining a normal static two-point discrimination of less than 6 mm.

Osseous and Tendinous Anatomy

The distal phalanx consists of a proximal flared base, an intermediate narrow shaft, and an expanded distal spatulate apical tuft. The terminal extensor tendon condenses onto the dorsal tubercle of the base (confluent with the epiphyseal physis in skeletally immature patients), while the FDP tendon inserts broadly onto the volar base. The absence of periosteal soft-tissue buffer between the sterile matrix and the dorsal cortical bone renders the nail bed exquisitely vulnerable to crush injury against the underlying skeleton.

3. Pathogenesis

Fingertip and perionychial injuries result from direct mechanical force vectors that compress, shear, or avulse the specialized cutaneous and subungual envelopes:

• Crush Vectors (Compression Injury): High-energy compressive loading between rigid surfaces (e.g., closing residential doors, industrial machine presses, automotive tailgates) generates acute hydrostatic expansion of the volar pulp and subungual spaces. The nailbed is compressed against the underlying dorsal cortex of the distal phalanx, resulting in burst lacerations of the sterile matrix and comminuted fractures of the terminal apical tuft.
• Sharp Shear Vectors: Saws, knives, and kitchen blades create linear or oblique amputations across the fingertip. The orientation of the laceration (volar oblique vs. dorsal oblique) dictates whether the residual pulp maintains vascular perfusion and adequate skeletal coverage.
• Avulsion and Degloving Vectors: High-traction forces (e.g., power takeoff shafts, machinery gears, ring-avulsion mechanics) detach the perionychial envelope or slide the sterile matrix off the dorsal phalanx. Complete avulsion of the germinal matrix from beneath the eponychial fold leaves an open cul-de-sac that will rapidly fibrose and obliterate the nail sulcus if not promptly anatomically stented.
• Pediatric Epiphyseal Failure (Seymour Mechanism): In skeletally immature children, the growth plate of the distal phalanx (Salter-Harris I or II) represents the mechanical weak link. Hyperflexion crush injuries cause dorsal displacement of the distal phalanx shaft relative to the epiphysis. Because the terminal extensor tendon inserts onto the proximal epiphyseal fragment while the nail bed is adherent to the distal shaft, the proximal edge of the nail matrix herniates out from beneath the eponychial fold and becomes trapped inside the open fracture gap.

4. Natural History

Traumatic injuries to the fingertip and nail unit account for up to 10% of all presentations to emergency departments and urgent care centers, representing the single most frequent traumatic hand pathology. The condition displays a marked bimodal epidemiological distribution: a major pediatric peak in toddlers aged 1 to 4 years (nearly 70% resulting from door crush mechanisms) and a secondary adult peak in young males aged 20 to 45 years involving power tools and occupational equipment.

When managed inappropriately or neglected, the natural history of perionychial and fingertip trauma leads to severe long-term functional and psychological morbidity:

• Split Nail Deformity: Unrepaired longitudinal tears in the germinal matrix heal with dense fibrous scarring. Because scar tissue cannot produce keratinized onychocytes, the regenerating nail plate splits longitudinally into two discrete plates, creating painful snagging on clothing and chronic distal fissure infections.
• Hook Nail (Parrot-Beak Deformity): When more than 3 to 5 mm of distal phalanx tuft support is lost, the sterile matrix and nail bed contract volarly over the rounded apex of the shortened bone. The regenerating nail curves downward into the volar pulp, eliminating pinch mechanics and causing persistent pressure pain.
• Subungual Pterygium and Non-Adherence: Desquamated or scarred sterile matrix loses its micro-ridges, preventing adhesion of the nail plate. The nail elevates from the nailbed (onycholysis), accumulating subungual debris and hosting secondary fungal or bacterial colonizers.
• Neuroma and Chronic Hypersensitivity: Sharp transection or crush disruption of arborizing terminal digital nerve branches without adequate soft-tissue padding leads to painful terminal neuromas, debilitating cold intolerance, and reflex guarding that produces secondary joint stiffness across the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints.

5. Clinical Presentation

History

A systematic clinical history must document patient hand dominance, exact occupation, musical or athletic hobbies, timing of injury, and tetanus vaccination status. Crucial historical details include:

• Mechanism of Injury: Sharp guillotine transection, high-energy blunt crush, grinding machinery, high-pressure chemical/paint injection, or thermal burn.
• Contamination Level: Exposure to soil, marine environments, sewage, organic matter, or farm equipment.
• Amputated Part Status: Whether the amputated fingertip composite is available, clean, and appropriately cooled (wrapped in sterile saline-dampened gauze, placed in a sealed plastic bag, and rested on ice water—never submerged directly in water or frozen on dry ice).

Physical Examination

Examination of the injured fingertip requires adequate lighting, gentle irrigation, and digital anesthesia (performed before extensive probing). A standardized exam sequence ensures zero missed injuries:

• Vascular Perfusion Assessment: Inspect pulp color, capillary refill time (<2 seconds normal), and pulp turgor. Evaluate digital artery patency via selective digital Allen compression testing.
• Neurological Evaluation: Test static two-point discrimination along both the radial and ulnar digital borders using a blunt discriminator prior to local anesthetic infiltration. Normal static 2PD is <6 mm; 6–10 mm represents fair sensation; >10 mm indicates significant neurovascular trunk transection.
• Tendon Excursion Integrity:
  Flexor Digitorum Profundus (FDP): Manually stabilize the PIP and MCP joints in full extension and ask the patient to actively flex the DIP joint. Inability to flex indicates an avulsion (Jersey finger) or laceration proximal to the insertion.
  Terminal Extensor Tendon: Stabilize the middle phalanx and assess active DIP joint extension against mild resistance. Extensor lag >20° indicates terminal tendon disruption or bony mallet fracture.
• Perionychial Unit Inspection:
  Subungual Hematoma: Quantify the percentage of visible nailbed surface involved (<25%, 25–50%, >50%).
  Nail Bed Integrity: Evaluate for nail plate subluxation out of the proximal eponychial sulcus, laceration of the paronychial folds, or visible exposed phalanx. In children, carefully examine the eponychium for the proximal edge of the displaced nail plate to rule out a Seymour fracture.
• Amputation Geometry: Determine the plane of tissue loss (transverse, volar oblique, dorsal oblique) and quantify the remaining pulp and exposed cortical bone dimensions.

6. Imaging and Diagnostic Studies

Standard Radiographic Protocol

Standard plain radiography is mandatory for all fingertip and nailbed injuries to identify occult fractures, foreign bodies, and joint subluxations. Dedicated digital views must be ordered rather than a general hand series to avoid beam obliquity and superimposition:

• Dedicated Digital Anteroposterior (AP) View: Evaluates transverse apical tuft fractures, distal phalanx comminution, and coronal plane displacement.
• True Lateral Digital View: The gold standard view for identifying Seymour fractures (juxta-epiphyseal physeal widening or displacement), dorsal mallet avulsion fragments, volar FDP bony avulsion fragments, and the degree of dorsal cortical bone support beneath the sterile matrix.
• Dedicated Oblique View: Enhances identification of subtle comminution and radiopaque foreign bodies (glass, metal splinters).

Radiographic Measurements and Diagnostic Benchmarks

• Tuft Comminution vs. Shaft Fracture: Tuft fractures are treated according to the overlying soft-tissue envelope. Transverse shaft or base fractures represent inherently unstable patterns that compromise tendon attachment and often require temporary stabilization.
• Pediatric Seymour Fracture Criteria: Any widening or dorsal displacement of the distal phalanx epiphysis in conjunction with soft-tissue swelling or nail plate disruption on the lateral radiograph must be classified as a Seymour fracture.
• Articular Step-off: Intra-articular fracture extensions into the DIP joint measuring >1 mm or involving >25% of the articular surface indicate unstable mallet or FDP avulsion variants.

Advanced Modalities

Advanced imaging is rarely indicated in the acute presentation. High-frequency diagnostic ultrasound (15–22 MHz) is highly sensitive for identifying radiolucent organic foreign bodies (e.g., wooden splinters, thorns) or evaluating post-traumatic subungual masses (such as post-traumatic glomus tumors or epidermal inclusion cysts) presenting weeks to months after initial trauma.

7. Classification

Validated classification systems guide operative decision-making by categorizing the anatomical level of tissue loss, the geometric angle of the amputation plane, and the involvement of the perionychial matrix:

Allen Classification of Fingertip Amputations (1980)

Rosenthal / Guy Geometric Plane Classification

8. Treatment

Medical / Nonoperative Management

• Subungual Hematoma Trephination: In the presence of an intact nail plate and stable perionychial margins, acute subungual hematomas should be treated with immediate bedside decompression (trephination) using a heated 18-gauge needle, fine battery-operated electrocautery, or a dedicated puncture device. Trephination provides instant pain relief by relieving elevated hydrostatic subungual compartment pressure.
  Clinical Rule: Routine nail plate avulsion is not required solely because a subungual hematoma exceeds 50% of the nail surface, provided the nail margins are intact and the radiograph demonstrates an undisplaced tuft fracture. The nail bed is explored only if there is visible laceration of the eponychial or paronychial folds, active uncontrolled subungual hemorrhage, or a displaced distal phalanx fracture.
• Secondary Intention Healing (Semi-Occlusive Dressing): First-line gold standard for Allen Type I and small Type II (<1 to 1.5 cm²) fingertip amputations, particularly in pediatric patients and adult non-heavy laborers.
  Protocol: Meticulous antiseptic cleansing, conservative debridement of non-viable tissue, and application of a semi-occlusive dressing (e.g., polyurethane film like Tegaderm, silicone-coated mesh like Mepitel, or hydrocolloid wafer) changed weekly. Granulation occurs within 7–14 days, followed by re-epithelialization by 3–4 weeks. Produces exceptional sensate skin with near-normal two-point discrimination and restores rounded apical contour without donor site morbidity.
• Pharmacotherapy & Prophylaxis: Update tetanus toxoid booster (0.5 mL IM if >5 years since last dose or status unknown). Routine prophylactic antibiotics are unnecessary for clean, isolated nailbed repairs but are mandatory for grossly contaminated injuries, animal bites (amoxicillin-clavulanate), or open distal phalanx fractures (first-generation cephalosporin or clindamycin).

Operative Management

• Surgical Goals: Restore a smooth, non-adherent nail bed; prevent synechiae of the germinal cul-de-sac; preserve maximum distal phalanx length with stable soft-tissue coverage; maintain tactile sensation; prevent hook nail or neuroma deformity.
• Anesthesia & Hemostasis: Digital nerve block or wide-awake local anesthesia no tourniquet (WALANT) using 1% plain lidocaine or 1% lidocaine with 1:100,000 epinephrine. Digital tourniquet control is achieved via a sterile finger glove cut at the digit tip and rolled proximally, or a commercially designed silicone digital ring tourniquet (strictly limited to <60 minutes).
• Nail Plate Avulsion & Loupe-Assisted Debridement: If the nail plate is partially avulsed or disrupted, gently separate it from the sterile matrix using a straight Iris scissors or a Freer elevator advanced from distal to proximal. Preserve the removed plate in sterile saline. Inspect the entire matrix under 2.5x to 3.5x optical loupe magnification. Debride crushed, non-viable wound edges minimally.
• Meticulous Matrix Repair:
  Sterile Matrix: Reapproximate edges anatomically using interrupted 6-0 or 7-0 fast-absorbing monofilament (polyglactin 910 or chromic gut) on a small spatulated micropoint needle. Alternatively, 2-octylcyanoacrylate (tissue adhesive) can be applied to reapproximated dry matrix edges, eliminating suture puncture tracks and reducing operative time.
  Germinal Matrix: Repair carefully with 6-0 or 7-0 chromic gut. Avoid tension to prevent scar contracture and subsequent split nail growth.
• Stenting the Eponychial Fold: The germinal matrix roof and floor must be prevented from adhering to each other. Replace the cleansed native nail plate (fenestrated with several 18-gauge needle holes to allow hematoma drainage) into the eponychial fold. If the native plate is crushed, lost, or contaminated, stent the fold using a sterile non-adherent foil wrapper (suture pack foil), a silicone sheet, or a trimmed plastic syringe sheet. Secure the stent with a single 5-0 nylon horizontal mattress suture passed through the lateral paronychium or distal tip, avoiding direct puncture of the germinal matrix. Stents are maintained for 10 to 14 days.
• Pediatric Seymour Fracture Reduction: Under digital or general anesthesia, thoroughly irrigate the fracture hematoma. Extract the herniated germinal matrix out of the fracture site using a skin hook. Reduce the Salter-Harris fracture under fluoroscopic guidance. In unstable patterns, stabilize with a single axial 0.028-inch or 0.035-inch K-wire placed across the DIP joint. Repair the disrupted nail bed and stent the eponychial fold. Administer oral antibiotics for 7 days.
• Reconstructive Flaps for Soft-Tissue Loss:
  Atasoy-Kleinert Triangular Volar V-Y Flap: Indicated for transverse or dorsal oblique amputations with exposed bone. A triangular skin flap with its apex at the DIP flexion crease is incised through dermis only; fibrous vertical pulp septa are sharply released while preserving neurovascular branches. The flap is advanced distally 3–5 mm over the exposed tuft and sutured without tension.
  Kutler Bilateral Lateral V-Y Flaps: Indicated for transverse amputations with limited lateral pulp. Two triangular flaps are mobilized from the mid-axial digital lines and advanced toward the midline.
  Cross-Finger Flap: Indicated for substantial volar oblique defects in index, middle, or ring fingers (>1.5 cm² exposed bone/tendon). A full-thickness fasciocutaneous flap is elevated from the dorsum of the adjacent middle phalanx and inset onto the recipient volar pulp, with division and inset at 2–3 weeks.
  Moberg Volar Advancement Flap: Reserved almost exclusively for thumb pulp amputations. Both neurovascular bundles are mobilized with the entire volar skin sleeve. Avoided in triphalangeal fingers due to severe risks of dorsal skin necrosis and PIP joint flexion contractures.

Indications & Contraindications

9. Outcome

Long-term clinical outcomes following fingertip and perionychial trauma are heavily dictated by the reconstructive modality selected, the quality of anatomical matrix repair, and patient age:

• Sensory Re-Innervation & Discriminative Touch: Secondary intention healing produces the most superior discriminative sensation, with static two-point discrimination recovering to 3–5 mm in children and 5–7 mm in adults, outperforming full-thickness skin grafts (6–9 mm) and regional cross-finger flaps (7–10 mm). Local V-Y advancement flaps preserve original innervated pulp, restoring static 2PD to within 1–2 mm of the uninjured contralateral digit.
• Nail Regrowth Kinetics and Cosmesis: Complete regeneration of the adult fingernail requires 70 to 160 days. Growth proceeds with an initial temporary growth arrest groove (Beau’s line) or transient thickening during the first 6 weeks. Anatomical repair of the sterile matrix achieves satisfactory cosmetic nail appearance in >85% of cases. Failure to repair lacerations or deep crush disruption results in late nail deformity rates exceeding 30%.
• Patient-Reported Outcome Measures (PROMs): Patients undergoing conservative secondary intention healing achieve QuickDASH scores under 5 points and return to work/play an average of 14 days earlier than those managed with primary revision amputation or regional flap transposition.

10. Complications

Complications following perionychial trauma range from early infectious wound failures to permanent structural nail deformities and debilitating sensory pain syndromes:

11. Pearls and Pitfalls

• Surgical Pearl (Preserve the Bony Scaffold): When addressing comminuted tuft fractures beneath a crushed nail bed, resist the temptation to aggressively rongeur away small bone fragments. As long as soft-tissue attachments remain, distal phalanx fragments provide crucial scaffolding that prevents late hook nail contracture. Contour only sharp, spike-like cortical projections that directly puncture the matrix.
• Surgical Pearl (Loupe-Assisted Precision): Never attempt nailbed repair without optical magnification (2.5x to 3.5x). The sterile matrix is less than 1 mm thick. Using fine 7-0 absorbable sutures on spatulated needles prevents full-thickness tearing and avoids creating secondary iatrogenic scars that induce late onycholysis.
• Diagnostic Pitfall (The Missed Seymour Fracture): In a young child presenting with a jammed finger and a subungual hematoma with blood oozing from the proximal eponychial fold, never assume this is a simple nailbed contusion. Always scrutinize the true lateral radiograph for juxta-epiphyseal physeal widening. Treating a Seymour fracture as a closed injury guarantees osteomyelitis and permanent growth disturbance.
• Technical Pitfall (Blind Trephination): Avoid aggressive electrocautery trephination directly over the thin germinal matrix (the proximal third beneath the lunula). Heat transfer can permanently burn the germinal matrix cells, transforming a benign subungual hematoma into an irreversible iatrogenic split nail deformity.
• Judgment Pitfall (The Over-Engineered Flap): Performing a regional flap (e.g., cross-finger or thenar flap) for an isolated Allen Type I or small Type II fingertip defect in a healthy patient introduces donor site morbidity, joint stiffness, and inferior sensation. Secondary intention healing is faster, safer, and achieves far better sensory recovery.

12. Controversy

Several long-standing dogmas in fingertip and nailbed surgery have been challenged by modern prospective trials and biomechanical investigations:

• Routine Replacement of the Fingernail Plate (The NINJA Trial): For decades, standard surgical teaching mandated replacing the native nail plate (or a synthetic stent) into the eponychial fold following nailbed repair to prevent eponychial adhesions and splint the repair. The landmark NINJA multicentre randomized controlled trial (Jain et al., Br J Surg 2023, n=454 children) evaluated nail bed repair with versus without nail plate replacement. At 4 months post-injury, there was no statistically significant difference in surgical site infection rates (3.5% replaced vs. 2.2% not replaced) or cosmetic nail appearance. While many surgeons continue to use synthetic non-adherent stenting in complex germinal matrix disruptions, the NINJA trial proves that routine replacement of the traumatized, contaminated native plate is not mandatory for uncomplicated sterile matrix lacerations in children.
• 2-Octylcyanoacrylate (Tissue Adhesive) vs. Microsuture: Traditional repair utilizes interrupted 6-0 or 7-0 absorbable sutures. A prospective randomized controlled trial by Strauss et al. (J Hand Surg Am 2008) compared 2-octylcyanoacrylate tissue adhesive to suture repair in 40 patients. Suture repair required significantly longer operative times (27.8 vs. 9.9 minutes, p<0.001), while cosmetic outcomes, functional pain scores, and complication rates were identical at 6 months. Tissue adhesive eliminates suture needle tracks and offers particular utility in the pediatric emergency setting, although meticulous hemostasis and dry wound edges are mandatory for proper bonding.
• Subungual Hematoma: Trephination Thresholds: Classical textbooks recommended formal nail plate removal and exploratory repair whenever a subungual hematoma involved >50% of the nail surface. Multiple prospective series have refuted this dogma, proving that trephination alone achieves equivalent outcomes with zero increase in late nail deformity, provided the peripheral nail margins are intact and the underlying distal phalanx fracture is non-displaced. Formal exploration is now reserved strictly for unstable fractures or disrupted nail folds.

13. Evidence-Based Synthesis

Modern clinical decision-making is grounded in high-quality randomized controlled trials and prospective registry analyses, corroborated by seminal biomechanical and anatomical descriptions.

14. References

• Jain A, Greig AVH, Jones A et al. Effectiveness of nail bed repair in children with or without replacing the fingernail: NINJA multicentre randomized clinical trial. Br J Surg. 2023. doi:10.1093/bjs/znad031 [Level I: Randomized Controlled Trial]
• Strauss EJ, Weil WM, Jordan C et al. A prospective, randomized, controlled trial of 2-octylcyanoacrylate versus suture repair for nail bed injuries. J Hand Surg Am. 2008. doi:10.1016/j.jhsa.2007.10.008 [Level I: Randomized Controlled Trial]
• Zook EG, Guy RJ, Russell RC. A study of nail bed injuries: causes, treatment, and prognosis. J Hand Surg Am. 1984. doi:10.1016/s0363-5023(84)80153-7 [Level IV: Clinical Case Series / Cohort Study]
• Krauss EM, Lalonde DH. Secondary healing of fingertip amputations: a review. Hand (N Y). 2014. doi:10.1007/s11552-014-9663-5 [Level IV: Clinical Case Series / Cohort Study]
• Atasoy E, Ioakimidis E, Kasdan ML, Kutz JE, Kleinert HE. Reconstruction of the Amputated Finger Tip with a Triangular Volar Flap. The Journal of Bone & Joint Surgery. 1970. doi:10.2106/00004623-197052050-00006 [Level IV: Landmark Original Description / Case Series]

15. Master Class Pro-Tip

When repairing a jagged nailbed laceration with associated distal phalanx comminution, avoid the temptation to over-shorten or aggressively rongeur the distal tuft. Preserving the osseous dorsal cortical ledge is the primary mechanical barrier against catastrophic postoperative hook nail deformity. Debride only non-viable bone fragments, reduce the nailbed anatomically over the bony scaffold with 7-0 fast-absorbing monofilament under loupe magnification, and secure a fenestrated stent into the germinal fold with a single 5-0 nylon horizontal mattress suture passed through the lateral paronychium to maintain the proximal cul-de-sac without puncturing the germinal matrix.

Master Class Surgical Pearl: Nail Bed Reconstruction and Tuft Support