Anatomy of Feet, Toes, and Toenails

Nearly one-fourth of all bones in the human body are in the feet. The foot is a complex, flexible structure that contains bones, joints, and more than 100 muscles, tendons and ligaments, all working together to enable movement and balance. The foot is divided into three sections, the forefoot, the midfoot and the hindfoot. The forefoot has five toes (14 phalanges) and five longer bones (metatarsals). One phalanx of each of the five toes connects to one of the five metatarsals. Each of the four lesser digits, or smaller toes, contains three joints.

The tip of each toe is protected from injury and infection by a toenail, which is made of keratin, a fibrous, amino acid protein that is also present in the fingernails, hair and skin.

Nail plate—The hard, visible part of the nail that grows longer and requires trimming

Nail matrix—Structure at the nail base, where new toenails form

Nail fold—Soft tissue border around the nail plate; helps protect the edges of the nail plate and nail matrix from trauma and ultraviolet radiation

Nail bed—Tissue and skin under the nail plate that supports healthy nail growth and secures the place

Cuticle—Seal of soft tissue at the nail base that grows from the nail bed and attaches to the nail plate

Hyponychium—Skin under the free edge of the nail plate, at the very tip of the toe

Onychodermal band—Seal of tissue that marks where the nail plate separates from the hyponychium

What is a Toenail Injury?

A toenail injury can range from minor damage to severe trauma, and is often the result of blunt force, such as dropping a heavy object on the toe or stubbing it. Injuries can also occur when a toe makes repetitive contact with a shoe, especially if it is ill-fitting.

Some common toenail injuries include:

  • Avulsion, or ripping of nail from the nail bed, resulting in complete or partial detachment
  • Bruised, crushed or smashed nail
  • Cracked, torn or split nail
  • Lacerations or deep cuts to the nail
  • Onycholysis, an underlying condition that causes gradual separation from the nail bed
  • Splinter or other foreign object under the nail
  • Subungual hematoma, where blood pools under the bruised nail

Symptoms of a Toenail Injury

If you experience any of the following, it’s important to seek treatment from your podiatric specialist immediately.

  • You suspect nail trauma and have a medical condition such as diabetes, neuropathy, compromised immune system, or peripheral arterial disease
  • Redness, pain or swelling increases or lasts for a day or more
  • Bleeding is severe and does not stop when pressure is applied
  • Complete avulsion or separation of the nail from the nail bed
  • Nail is pulling away at the base or sides
  • Nail is torn too far down for you to trim yourself
  • Signs of an infection, such as fever, redness, swelling, increased pain and soreness, discharge or puss
  • Affected toe is also misshapen or misaligned

Causes and Risk Factors

Some common causes and factors that can increase your risk of injuring a toenail, include:

  • Accidental impact or trauma, such as stubbing or striking the toenail or dropping a heavy object on the toe
  • Tight-fitting shoes
  • Bacterial or fungal toenail infections
  • Toenails are too long or untrimmed
  • Skin diseases such as psoriasis and eczema
  • Poor circulation
  • Repetitive stress or trauma to the nail from running, soccer or other activities that involve constant pressure on the toenails

Immediate First Aid

Apply first aid immediately to help control bleeding and prevent further injury or infection. While most minor toenail injuries can be managed at home, more severe trauma requires immediate professional care.

  • Gently cleanse with mild soap and water
  • Apply pressure with a clean cloth or gauze to control bleeding
  • Cover with a sterile bandage to protect the injury from dirt or other contaminants and prevent further damage
  • If the nail is partially or completely detached, reposition the nail, protect with a sterile bandage, and seek immediate medical care

Nonsurgical Treatment

Depending on your specific injury and its severity, treatment could include:

  • Relieving pressure and pain by draining blood and fluid
  • Reattaching the nail with special glue or stitches
  • Replacing the separated nail with special protective material that will remain during healing
  • Repairing the nail bed
  • Closing cuts or lacerations with stitches
  • Antibiotics to prevent infection

Pain Management

  • Wrap ice in a clean cloth and apply directly to the injured area for 15 to 20 minutes at a time, every two hours the first day; then three to four times a day after that.
  • Reduce throbbing by propping the affected foot up, higher than heart level.
  • Over-the-counter nonsteroidal anti-inflammatories (NSAIDs) such as ibuprofen and naproxen may be prescribed to relieve pain, sometimes in combination with acetaminophen. If you have serious contraindications to NSAIDs or your pain is not well-controlled, discuss other types of pain medication with your physician.

Healing and Recovery

A toenail injury requires time to heal. During that time, watch for any signs of infection, such as increased redness, swelling or discharge. If you lose the nail, it typically takes from a week to 10 days for the nail bed to heal, and from 4 to 6 months for growth of the replacement nail.

As a new nail grows in, there may be changes in appearance, and the old nail will eventually fall off. After an injury to your toenail, nail matrix, and/or nail bed, there are often permanent changes to the growth of the nail. This is because injury to the nail’s growth centers can alter the cell structure in these areas, leading to changes such as nail ridges, splits, thickening, or slow or incomplete growth.