Recently I had an opportunity to perform one of my favorite techniques, the transverse figure-of-eight suture to secure a partially avulsed toenail.

The patient was a young man who injured his toe kite boarding. Somehow he managed to lift the nail from its bed, miraculously had no underlying laceration to the bed (just a whole lot of sand!) and a pretty gruesome looking toe.

The transverse figure-of-eight technique is a handy trick to have in the back of your pocket for an avulsed (or partially avulsed) fingernail or toenail.

Rather than suturing through the nail (which is fairly tough to do, especially with a toenail) or trying to tack it down with a tissue adhesive glue (a reasonable option in many cases, but the patient was interested in the most secure closure possible), I used a little known technique from a described in the Journal of Hand Surgery many years ago that I’ve always found effective in these situations.

What I love about this technique in particular is:

  • there is no suturing in to the nail, which technically means driving a foreign body (nail spicule) through the nail bed if you enter the nail first
  • there is no suturing out through the nail, which is really challenging to do and when the nail is thick, & can bend and break your needle
  • there is no suturing within the eponychial or paronychial folds, which are sensitive structures that really should avoid any further damage, if you can help it

The technique is easy to learn as it is based on the basic figure-of-eight suture pattern.

  • Use a 4-0 nylon suture with a medium sized (eg P-11) cutting or reverse cutting needle, or similar equivalent.
  • Ensure adequate digital block is applied before you begin. Working on a finger or toenail bed is painful!
  • Instruct the patient to return for suture removal in 10-14 days.

Advise them that even with the best nail securing technique, with a severe enough injury loss of the native nail, dystrophic regrowth, and even failure to regrow the nail are possibilities.