HWN Suggests

The NINJA trial: Do you replace the fingernail after nail bed repair?

Nail bed injuries aren’t quite common enough to cause the same debates as TXA, or IV antibiotics, or tPa, but talk to 10 different emergency doctors and you are likely to get 10 different opinions about the management of these injuries. Therefore, even though the NINJA study doesn’t answer the most important question (in my mind), the fact that we have a large multicenter RCT looking at nail bed injuries means that it is a paper we should talk about.

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 Bye-bye, Fingernail? Not So Fast

One memory that stands out to me from early in my career was managing a distal finger injury from a lawnmower blade. I was concerned about a nailbed laceration, so what did I do? I did what was taught in residency from some textbooks and surgical consultants: I removed the nail, repaired any lacerations using absorbable sutures, and replaced it with a piece of foil using sutures to maintain patency of the eponychial fold. It was just my luck that my chair, Edward Panacek, MD, happened to be working that day, and after overhearing my case, he saw the patient and said I should have replaced the nail and used Dermabond to keep it in place. It turns out the “foil trick” I learned wasn’t a neat trick after all.

Articles of Interest

A Quick Guide to Nail Avulsion Therapy

Repair nail bed with 6-0 or 7-0 Chromic gut sutures. The nail bed is very fragile, so be gentle and insert suture needle distal to proximal, and use as few sutures as possible. Make sure the lac is aligned as precisely as possible. There have been several small studies that have shown that dermabond works just as well as sutures. In order to use it, you need to have a clean, bloodless field.

Acrylic Nail Injury

Okay great no fracture. Now what? How do you get the artificial nail off? How do you know if the nail bed is compromised? How do you know the biological nail is not fallen off with the artificial nail?

Approach to Nail Trauma

The subungual hematoma is probably the most common nail injury encountered in Emergency Medicine. Traditional dogma directed the provider to remove the nail to repair underlying injuries in the presence of >25-50% hematoma. This recommendation left many of us scratching our heads. We would go through the elaborate procedure of removing the nail by dissecting the nail away from the underlying nailbed, meticulously repairing a nailbed laceration if required, and then stenting the eponychial fold open, hoping that a normal nail would regrow without deformity despite the trauma from the injury and the procedure itself. It seemed like we were introducing a lot of trauma to the nail bed and eponychial fold for a theoretical (non evidence based) benefit. The more we did this, the more many of us would ask ourselves, “What if we just left this alone?”

Artificial fingernails: Too hot to handle

Acrylic nails lengthen the nail plate, and longer nails are subject to greater and more frequent trauma, sometimes causing the nail plate to separate from the underlying nail bed. In addition, when acrylic nails are first applied, the surface of the natural nail plate is often abraded to improve bonding of the acrylic. When the artificial nails are removed, the surface layers of the nail are subjected to further injury.

Assessment and Initial Care of Fingertip and Nailbed Injuries

Whether required due to a crushing blow or close contact with a sharp surface, proper initial care for fingertip and nailbed injuries is essential to good outcomes and can often be administered in the urgent care setting.

Clinical Conundrum: Do I Have to Replace the Nail After an Avulsion?

Bottom Line: Despite the classic teaching, the best available evidence doesn’t show a cosmetic difference between replacing the nail and not replacing the nail in pediatric patients. You would be well supported by the data if you chose to skip nail replacement.

Evidence-based Approach to Nailbed Injuries: ED Presentations, Evaluation, and Management

Greater than 50% of patients who present to the ED with nailbed injuries will also have an underlying distal phalanx fracture. As such, it is recommended that all patients with nailbed injuries receive an X-ray to evaluate for fracture or dislocation.

Nail Bed Injury and Repair

Amputation Pulp only: If patient is younger than two no reattachment is indicated, good outcomes with simple dressing. If over two and the amputated tissue is usable, de-fatting and reattachment is indicated. Otherwise, simple sterile dressing and consideration of plastics referral. Pulp and nail/bone: Emergency plastics consultation, wash and dress site of amputation, obtain x-rays. Keep stump covered with moist gauze. Keep severed tissue in an ice water bag, avoid contact with ice.

Nail Bed Laceration and Repair in the Emergency Department

Distal phalanx injuries are the most common hand injury, particularly in children. These are often due to crush injuries also resulting in subungual hematomas and nail bed lacerations. If a subungual hematoma involves more than half the nail plate, there is a 60% chance of a nail bed laceration and a high likelihood of fracture. If a distal phalanx fracture is present, there is a 95% chance of a nail bed laceration. There is controversy about how to repair nail bed lacerations; however, current evidence and recommendations point toward less aggressive management as the way to go.

Nail Bed Lacerations

Nail bed injuries in kids are COMMON! Significant nail bed lacerations MUST be evaluated and repaired to avoid bad cosmesis. Cyanoacrylates may be as effective as suturing for nail bed injury repairs in children. Unless a bite injury necessitates antibiotic treatment, clean injuries including open fractures are not proven to benefit from prophylactic antibiotics. Now you can Nail this one!

Nailbed Injuries

The nail plate may be ripped off by some form of trauma. This is known as a “nail avulsion.” The nail may be partially or completely gone, or may just be lifted up off the nail bed.

Nailbed Injuries, Part I

Nail bed injuries can be challenging for the emergency practitioner. They are variable in their degree of severity and complexity, and there is no great consensus on a single best way to manage them. A lot of what we do is based on common teaching from the hand surgery literature, with very little evidence driving our practice. The bright side of this is that it leaves a lot of room for practicing the “art” of medicine.

POTD: Trauma Tuesday - Nailed it!

What really matters most on initial inspection is any disruption to the proximal nail fold and lunula, which would suggest damage to the germinal matrix. Your fingernail grows from the germinal matrix, so if there is any disruption to that, the answer is easy. Stop and consult hand surgery. This patient is going to need a germinal matrix graft which is beyond our scope as ED docs. However, if you note that the proximal nail fold and lunula look largely intact and all you have is a laceration to the nailbed + an avulsed nail, you can take care of that!

Trick of the Trade: Nail Bed Repair With Tissue Adhesive Glue

Nail bed repair with Dermabond (and likely all tissue adhesive glues) may be a reasonable alternative to sutures for both nail bed laceration repair itself, as well as to hold the nail in place.