Nail It Down

This column provides a general overview of Roller Derby medical problems and their initial treatment, and it is not intended for advice for an individual. Therefore, you must consult appropriate medical professionals for advice in treating any injury or medical problem that you specifically have. This manual is not intended to be a complete or final guide to medical treatment of anyone's individual medical injury or problem.

With derby skaters, I see a lot of injuries to the nails of fingers and toes. Some injuries I seem to see most often are described below.

A tear-back injury is where the nail is ripped back from the nail bed. If there is laceration of the skin around the nail, sutures may be needed. If only a small area of nail is torn back, it may be removed to avoid catching on fabrics. Unless completely torn off and lost, the nail is usually best left in place. A simple dressing will suffice if the nail is only partly torn away. If the whole nail is torn away, sutures may be needed. Ice, elevation, and pain medicines likely will be needed at first.

The new nail will re-grow in about 2 - 4 months, usually after 2 - 3 weeks of no growth. In 2 - 3 weeks, the nail bed usually dries and toughens so discomfort is much less, and a simple covering is all that is needed. Initially, we treat the injury as an open burn would be. Silastic toe caps are useful in protecting the nail as it grows back.

A hematoma (collection of blood) under the toenail is caused by stubbing or dropping things on the toe, and in fingernails by direct trauma such as from a door or a hammer. Since the bleeding under the nail has no outlet, pressure develops, causing severe throbbing pain.

If there is severe throbbing pain, puncturing the nail with a red-hot paper clip or electro-cautery tool will relieve the pressure. Be sure to take precautions to contain the spray of blood. Although it sounds brutal, as the hot tip goes through the nail and hits the blood, it cools rapidly. The procedure is surprisingly pain-free. After the puncture, you must protect the area from infection for a week or two.

Chronic traumatic separation of the great toenail is an injury we have seen several times in our league. What apparently happens is repeated small injuries (stubbing the toe repeatedly or too tight a skate) to the great toe cause enough injury for the nail to separate from the nail bed. There is discomfort rather than major pain. This must be distinguished from a nail fungus infection.

In both, the nail becomes discolored (yellowish-white, gray). A fungus infection usually causes the nail to be crumbly and friable and may involve more than one nail. On occasion, a culture of the nail may be needed to rule out a fungal infection. A new nail will grow in under the separated nail in 2 - 4 months. The separated nail gradually loosens enough to easily remove it. Protecting the old nail from tearing away too early is accomplished with taping or silastic toe caps.

Ingrown toenails are painful and common. Usually it is the great toe that is involved. A nail in-grows when the front edge cannot clear the skin pad at the side of the toenail. Because the nail is pushed out from the cuticle as it grows, the nail catches in the skin and causes inflammation. Prevention is easier than treatment. The nail should always be cut in a straight line, allowing the
the nail to protrude slightly ahead of the skin pad.

Once the nail is ingrown, soaking the nail in hot water to soften it, filing the center top of the nail thinner to allow the edges of the nail to “pop up” more, wedging the nail up with vaseline gauze, and applying povidone-iodine (Betadeine®) to the crease of the nail to soften the nail and protect from infection will all help the milder cases. If the ingrown nail is infected, you must receive treatment for that first. In severe cases, a podiatrist may have to remove a strip of nail.