Copious irrigation is required with all wounds, with extra attention paid to open fractures If wound debridement is felt to be required, the emergency physician should consult with a hand specialist to avoid debriding vital structures such as the nail bed, which could result in permanent effects on subsequent nail growth Management Severe nail bed injuries require nail removal if nail avulsion was not part of the initial injury Wounds should be cleaned and the often friable tissue should be repaired with 5-0 or 6-0 absorbable suture, typically chromic gut Newer studies in both adults and children have found equivalent outcomes using tissue adhesive Common practice is to keep the nail fold open for the new nail to form; available placeholders include the salvaged nail, sterile aluminum (from suture packaging), or a nonadhesive dressing The placeholder should be secured to the fingertip, commonly with sutures, both proximally and distally to ensure that it does not get removed prematurely Care must be taken to avoid further damage to the germinal matrix and injury site when affixing the nail Absorbable sutures are preferred; if nonabsorbable sutures are used, they should be removed early in the course at follow-up with a hand specialist, to prevent wound tracks during nail development Tissue adhesive has been used as an alternative to sutures to secure the placeholder While some recent literature suggests that stenting the nail fold may not be necessary, supporting data are limited at this time and therefore current recommendations are to aim to maintain a patent nail fold