Lifting injuries to toe nails, especially to big toenails, are not uncommon. However, this injury often does not receive the proper medical care it requires due to the perception that the injury is minor. While true in many cases, there are times in which this injury can lead to significant complications, and in general many people treat this injury incorrectly from the start.
The toenail is a loosely attached piece of hard compressed tissue that grows from cells located behind the cuticle, under the skin. The nail cannot stay ‘glued’ down onto the skin below it because it has to move forward as it slowly grows. For this reason, any injury that catches under the edge of the nail, or smashes down on the nail causing bleeding under the nail can cause lifting of the nail itself, sometimes causing it to tear off completely (or at least close to it). The natural response by most people is to try and reattach the nail back on the skin through tape, a dressing, or even glue. Unfortunately, in certain circumstances, this can lead to various problems. When an injury is strong enough to rip the nail off, it may be strong enough to cause damage to the bone at the tip of the toe, which is near where the nail grows from in the first place. Toe fractures in and of themselves are generally not serious, but fractures associated with tearing or bleeding of the skin surface underneath the nail can be if the small pieces of bone are exposed to open air. This can lead to bone infection, which is difficult to treat in the toes and can lead to a partial toe amputation. This is especially true in diabetics or those with poorly functioning immune systems.
When one has experienced a toenail injury that has caused the nail to lift up or off, it is important to see a physician (preferably a podiatrist) for careful evaluation of the skin under the lifted nail, as well as possible x-rays if a fracture is suspected. Sometimes the nail must be completely removed to drain blood, inspect the nail bed for bone fragments or tissue tears, or to prevent bacteria and fungus from growing underneath it and causing an infection that may be difficult to treat. The nail will grow back, although it should be understood that any injury strong enough to lift the nail has likely also injured the nail root, and the nail growth that follows will likely be different forever. The nail may now grow thick, malformed, or curved inward. If bone fragments are noted, the area must be medically cleansed, antibiotics must be taken, and proper wound care must be performed under the direction of a physician in order for the area to heal properly and without infection.
One exception to this advice is when athletes like runners have toenails fall off due to bruising under the nail from running. This is common, is related mainly due to continued toe pressure in shoes while running, and is rarely associated with more traumatic injuries like fractures.
Scott R. Kilberg DPM 