Hand & Wrist

Nailbed Injuries

Most nailbed injuries heal well when the germinal matrix is repaired precisely and promptly. Dr. Peter FitzGibbons treats nailbed injuries and their associated fingertip fractures for children and adults throughout Montgomery County in Bethesda and Germantown.

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What is nailbed injuries?

A nailbed injury is damage to the tissue beneath the fingernail, usually from a crush, laceration, or door-closure injury, and often involves an underlying fracture of the fingertip bone. Treatment ranges from simple drainage of blood under the nail to nail removal with direct repair. In children, a Seymour fracture is a distinct, infection-prone variant requiring prompt care.

The complete nail structure is called the perionychium, made up of the nail plate, the nail bed beneath it, and the surrounding soft tissue (PMC; StatPearls). The nail bed itself has two functionally distinct zones. The germinal matrix sits at the base, beneath the visible white crescent (the lunula), and is responsible for approximately 90 percent of nail growth. The sterile matrix extends from the lunula to the tip of the finger; it is richly supplied with blood vessels and helps the growing nail plate adhere to the bed as it moves forward, though it contributes far less to actual growth than the germinal matrix (StatPearls). The eponychium is the soft fold of skin just above the nail, and the hyponychium is the tissue at the tip of the finger beneath the free edge of the nail, which forms a barrier against infection. Nails grow at roughly 0.1 millimeter per day, about 3 millimeters a month, somewhat faster in younger people and in fingers than toes (PMC).

Because the germinal matrix does almost all of the work of producing new nail, damage there, rather than damage to the sterile matrix, is what determines whether a nail grows back normally or with a lasting deformity. This is the single most important concept in treating these injuries: the goal of repair is not just to close the wound, but to restore the germinal matrix to its precise original position.

Why Nailbed Injuries Happen

The most common cause is direct trauma: crush injuries from a slammed door, machinery, or a hammer blow, sharp lacerations from an object forceful enough to cut through the nail plate, and avulsion injuries from crushing or grinding trauma (PMC; Orthobullets). Common specific mechanisms include a fingertip crushed between two objects, a finger caught in a closing door, and injuries from saws or snowblowers (Orthobullets). Fingertip injuries overall are the most common hand injury seen in hospital emergency departments, and they affect men roughly three times as often as women (Orthobullets).

Symptoms — do you recognize these?

Pain at the fingertip, often out of proportion to how minor the visible wound looks
Dark discoloration under the nail from blood collecting beneath the plate
A visibly bent, lifted, or displaced nail plate
A cut or crush wound over the nail fold or fingertip
Reduced strength bending the fingertip against resistance, which can indicate a concurrent tendon injury
In children specifically, a fingertip that looks bent like a mallet finger after a door or sports injury

Any nailbed injury with significant nail displacement, a large or very painful blood collection under the nail, or an associated wound should be evaluated the same day. In children, a bent, "mallet-like" fingertip after a crush injury needs prompt evaluation for a Seymour fracture, since a missed diagnosis carries a meaningfully higher infection risk the longer it goes untreated.

How we diagnose it

Physical examination. We assess disruption of the nail fold, motor function, sensation, and circulation of the entire finger (StatPearls). The extensor tendon at the fingertip joint is specifically tested by holding the middle part of the finger steady and checking straightening strength against the other hand, since weakness there points to a concurrent mallet finger injury (StatPearls).

Imaging. Three-view X-rays, front, side, and angled, should be obtained in every patient with a nailbed injury to look for an underlying fracture of the fingertip bone, which is common (StatPearls; Orthobullets). More than half of patients presenting to the emergency department with a nailbed injury turn out to have an underlying distal phalanx fracture (emdocs). Point-of-care ultrasound is increasingly used as a helpful add-on to identify nailbed lacerations and small tuft fractures, helping guide the decision about whether the nail needs to be removed for formal repair (StatPearls).

Treatment options

Observation for small, non-tense hematomas

A blood collection under the nail covering less than roughly half of the visible nail, in a patient without significant pain and without a fracture on X-ray, can be watched without any procedure.

When used: Small, minimally symptomatic subungual hematomas with a normal X-ray (PMC).

Trephination

A small hole is made through the nail plate, using a heated wire or a carefully applied needle, to release trapped blood and relieve pressure, providing rapid pain relief. Current evidence-based guidance favors trephination for essentially any acute, painful subungual hematoma presenting within 48 hours, regardless of its size, as long as the nail itself is not badly displaced or unstable, since outcomes track more closely with pain relief and nail bed integrity than with a strict size cutoff (StatPearls; Canadiem).

When used: Acute, painful subungual hematomas of essentially any size where the nail plate remains reasonably stable.

Recovery & rehabilitation

Fingernails typically regrow completely in about two months, though an injury involving the base of the nail can leave a lasting cosmetic change (Harvard Health). More detailed patient-education estimates put full regrowth at roughly three to six months after a repaired injury, with new growth becoming visible near the base within three to five weeks after repair before it progresses out toward the fingertip (Women's and Children's Health Network SA). The single most important factor in whether the new nail looks normal is whether the germinal matrix itself was injured and how precisely it was repaired; a smooth, accurately realigned repair usually produces a normal-appearing nail over time, while an imprecise or unrepaired laceration involving the germinal matrix carries real risk of permanent nail ridging, splitting, or deformity (Medscape; StatPearls).

Patients should expect the finger to be splinted or protected for one to two weeks after repair, with the replaced nail or synthetic substitute typically staying in place until it is naturally pushed out by the new nail growing in underneath it. We see patients in Bethesda and Germantown for follow-up to check healing and to catch any early sign of infection, which is the complication we are watching for most closely, particularly in children with a Seymour fracture.

Seymour Fracture: A Distinct Pediatric Injury

A Seymour fracture is a specific and easily missed injury in children and adolescents who still have an open growth plate. It is an open fracture of the fingertip bone at or near the growth plate, with an overlying nailbed laceration (PMC; Nationwide Children's Hospital). Clinically it can look like a simple mallet finger or a routine nailbed injury, because nailbed or germinal matrix tissue becomes trapped within the fracture site as the fingertip bone gets pulled one way by the deep flexor tendon and the growth plate fragment gets pulled the other way by the extensor tendon, producing a similar bent appearance (PMC). The reported average age at injury is 8.7 years, most often from a crush or sports injury (PMC).

The critical point for parents to understand is that a Seymour fracture is functionally an open fracture, communicating directly with the germinal matrix and nail fold, even when the overlying skin looks nearly intact. Delayed presentation or a missed diagnosis carries a reported infection rate as high as 45 percent, with 36 percent of those infections progressing to bone infection (osteomyelitis) when the child is not seen until more than 24 hours after injury (PMC). An untreated infection can damage the growth plate itself, causing growth arrest and a permanent mallet-type deformity of the fingertip (PMC). Treatment involves irrigation and cleaning of the wound, reduction of the fracture, and removing any trapped soft tissue from the fracture site, generally followed by antibiotics given the open nature of the injury. Because of the infection risk specifically tied to delay, any child with a bent, painful fingertip after a crush injury, especially with a nail that looks lifted or a dark line at the base of the nail, should be seen promptly rather than assumed to be a routine bruise.

Frequently Asked Questions

Does blood under my fingernail always need to be drained?

Not always, but current evidence favors draining most acute, painful collections regardless of size, as long as the nail plate itself is not significantly displaced or unstable. Older teaching focused on whether the blood covered more or less than half the nail, but outcomes track more closely with how much pain the patient has and whether the nail bed underneath is intact. Trephination, a small hole made in the nail to release the pressure, is quick and provides fast relief. If the nail is displaced or there's a suspected underlying laceration, formal removal and repair rather than simple drainage is usually the better path.

Will my nail grow back normally after an injury?

In most cases, yes, especially if the injury did not involve the base of the nail (the germinal matrix) or if that area was repaired precisely. Full nail regrowth typically takes two to six months, with new growth first visible near the cuticle a few weeks after repair. The main risk factor for a permanently abnormal-looking nail is damage to the germinal matrix that was not accurately realigned during repair, so we place particular care on that portion of the procedure.

What is a Seymour fracture and why is it treated differently?

It is a fracture of the fingertip bone near the growth plate in a child, with an overlying nailbed cut, most often from a crush injury such as a slammed door. It looks similar to a routine nailbed injury or mallet finger, but because the fracture communicates with the nail bed, it behaves like an open fracture even when the skin appears mostly intact. If not treated promptly, it carries a meaningfully elevated risk of infection, so children with this injury pattern are treated more urgently, with irrigation, fracture reduction, and often antibiotics, rather than simple observation.

Do I need to see a hand surgeon for a nailbed injury, or is the emergency room enough?

Many straightforward nailbed injuries, a small hematoma or a simple laceration with no fracture, are appropriately treated in an emergency department or urgent care. However, injuries with a displaced fracture, significant nailbed tissue loss, a suspected Seymour fracture in a child, or a laceration through the germinal matrix benefit from a hand surgeon's involvement, since precise repair of the germinal matrix specifically determines whether the nail regrows normally. If you are uncertain, call our office and we can advise on urgency.

How long will my child's finger be out of commission after a Seymour fracture repair?

Most children are splinted or protected for roughly two to three weeks while the fracture and nailbed heal, with activity restrictions eased gradually after that based on comfort and X-ray follow-up. Because a Seymour fracture is treated as an open injury, your child will likely receive a course of antibiotics started promptly after diagnosis. With timely treatment, most children recover normal finger growth and function; the main determinant of a poor outcome is a delay in diagnosis or treatment rather than the injury itself.

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Peter G. Fitzgibbons, MD

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Medically reviewed by Peter G. Fitzgibbons, MD, MD

Last reviewed August 5, 2026