One memory that stuck with me early in my career was dealing with an injury to the distal end of a finger caused by a lawn mower blade. I was concerned about a nail bed laceration, so what did I do? I did what was taught in residency in some surgical textbooks and consultants: I removed the nail, repaired all the lacerations using absorbable sutures, and replaced it with a piece of aluminum foil using sutures to maintain the patency of the eponymous fold.
It was just my luck that my president, Edward Panacek, MD, was working that day, and after hearing my case, he saw the patient and said I should have replaced the nail and used Dermabond for the keep in place. Turns out the “foil trick” I learned was not a cool trick after all.
Distal finger and nail bed injuries are common in emergency departments. Large studies on this topic are hard to find, so we are grateful for what is available to shed light on simple subungual hematomas, when nail plate removal is really needed, and practice changes. in the repair of the nail bed.
Subungual hematomas are the most common nail bed lesions in all age groups. Traditional dogma says to remove the nail plate and repair the underlying nail bed if there is a hematoma involving more than 50% of the nail. (NUEM blog. April 8, 2018; https://bit.ly/36AD572.) Fortunately, this has been discredited by numerous studies, and you can forgo long and laborious nail bed repair for a quick nail trephination, which is the preferred method of hematoma management if the nail plate and margin are intact. (Pediatric emergency care. 2014;30:742.)
One of the most cited studies involved 52 children with subungual hematomas and intact nail edges and plates. (J Hand Surg Am. 1999;24:1166.) They compared nail trephination with nail plate removal, finding no difference in results regardless of hematoma size or phalanx fracture.
Avoid removing the nail
The traditional practice of removing the nail plate and performing a nail bed repair is an elaborate and time-consuming procedure. This involves dissecting the nail away from its rich connective tissue from the nail bed, using absorbable sutures to repair the lacerations, and stenting the open eponychial fold using a piece of tissue paper. foil (usually from a suture container). Hopefully, the nail plate grows back properly and there is a reduced risk of long-term nail deformities if inserted correctly.
This teaching has been transmitted for many years to unfortunate residents and trainees in surgical specialties and then in emergency medicine. The evidence does not support this practice. Quite the opposite, in fact. There are very few indications for removing a nail plate. Most experts agree to remove the nail when the plate is significantly damaged (fractured, large laceration), the edge of the nail is damaged, or the patient has a severely displaced open distal phalanx fracture. You should not remove the nail plate if none of these are present.
Many patients do not meet these criteria and do not need plaque removal. You must perform a digital block, place a tourniquet for the fingers, and remove the nail plate by dissection of the nail bed for those who do. Carefully inspect the nail plate, clean the nail and place it in the eponymous opening if the part of the nail plate that fits into the eponymous opening is intact. There is no need for foil or suture container wrappers.
Evidence supports the use of the native nail plate instead of abandoning it for an artificial piece. A large retrospective study of 401 patients found that those who had native nail plate replacement had significantly less nail deformity than those who had a silicone splint placed. (World J Surg. 2014;38:2574.)
What about suturing nail bed lacerations or suturing the nail plate in place? A small prospective study of 40 patients directly compared repair time and aesthetic and functional outcomes in patients who had Dermabond with those who had sutures (6-0 Chromic). (J Hand Surg Am. 2008;33:250.) There was a significant impact on repair time, with Dermabond being much faster (9.5 mins vs. 27.8 mins). More importantly, no statistical differences in physician- or patient-judged esthetics and no changes in functional outcomes were observed. Limitations of the study included the small patient population and the fact that the procedure was performed by orthopedic residents, not emergency physicians, which shouldn’t matter.
Another prospective study performed on 30 children found similar results. (J Child Orthop. 2010;4:61; https://bit.ly/3i3cLrO.) Generalizability is limited in these two small studies, but it seems reasonable to use a native nail with Dermabond whenever possible when considering these results, the time required to perform the procedure, and the difficulty in finding, inserting and properly suture medium-sized artificial nail.
The next time you have a patient with a distal finger injury, first consider whether the nail needs to be removed. Subungual hematomas with intact edges and nail plates do not need to be removed from the nail and benefit the most from trephination. If the patient has an injury requiring removal of the nail plate (fracture or large nail laceration, nail margin injury, or severely displaced distal phalanx fracture), do not discard the nail plate. the original nail if it is intact. Clean the plate and replace it correctly in the eponymous opening, fixing it with Dermabond. Refer the patient to a hand surgeon.
Dr. Briggsis an assistant professor of emergency medicine at the University of South Alabama in Mobile. He is the founder, podcast co-host and editor of EM Board Bombs (https://www.emboardbombs.com), a cross-platform educational tool designed to prepare for counseling and focus on what you need to know to practice emergency medicine. Follow him on Twitter@blakebriggsmd.