Nail Bed Injury Victor Fehrenbacher, MD, Ethan Blackburn, MD THE PATIENT A 45-year-old manual laborer presents to the emergency department 6 hours after crushing his nondominant middle finger with a hammer. He has a large (60%) subungual hematoma involving the proximal nail bed, an intact nail plate, and a comminuted distal phalanx fracture. THE QUESTION Would this patient benefit from nail plate removal and nail bed repair? CURRENT OPINION Fingertip crush injuries are common and can injure the germinal and sterile matrix, both of which have a role in nail growth.1,2 The role of nail removal in the presence of subungual hematoma and crush injury is debated.3e6 Some believe that repair of acute nail bed injuries will minimize nail deformity7e9 and recommend repair using 6-0 or 7-0 absorbable suture under loupe magnification7e10 or with adhesives.11 Nail removal and nail bed repair is often recommended for subungual hematomas involving 50% of more of the visible nail plate. THE EVIDENCE A study of 47 patients with subungual hematomas involving more than 25% of the nail plate found a 60% incidence of 3 mm or greater fissures in the nail bed, 95% when there was an associated distal phalanx fracture.5 A study of 94 subungual hematomas treated with trephination alone found 85% excellent and very good results using Zook’s8 criteria (excellent ¼ normal; very good ¼ minor deformity).6 From the Department of Orthopaedic Surgery, University of Louisville, Kentucky. Received for publication July 17, 2014; accepted in revised form October 15, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Victor Fehrenbacher, MD, Department of Orthopaedic Surgery, University of Louisville, 550 S Jackson Street, 1st floor ACB, Louisville, KY 40202; e-mail: [email protected]. 0363-5023/15/4003-0030$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.10.024
A prospective study of 52 children with subungual hematomas involving more than 25% of the visible nail plate found no difference in outcomes between nail trephination and nail bed, repair with both groups having only transient nail abnormalities.3 Zook8 reported 90% good to excellent results in nearly 300 nail bed injuries treated with nail plate removal and nail bed repair under loupe magnification using 7-0 chromic gut suture and reduction and pinning of unstable distal phalanx fractures. Worse outcomes were associated with crush and avulsion type injuries and the rare infection. There was no difference with nail replacement compared with no replacement of the nail. Strauss et al11 used 2-octyl cyanoacrylate (Dermabond; Ethicon, Inc, Summerville, NJ) to repair 18 nail beds and used suture to repair another 22 nail beds. The 2-octyl cyanoacrylate group had 15 excellent, 2 very good, and 1 poor result, and the suture repair group had 17 excellent, 4 very good, and 1 good results based on physician-evaluated cosmetic appearance. O’Shaughnessy et al12 compared 10 patients where the nail was replaced after nail bed repair with 54 patients where the nail bed was not replaced after repair. They found no significant difference in the appearance of the nail or the rate of re-growth, but crush injuries were worse in both groups. SHORTCOMINGS OF THE EVIDENCE The natural history of nail growth and nail deformity after crush injury and subungual hematoma is uncertain. Subungual hematomas are common, and associated fissures in the nail bed are common as well, but substantial nail deformities from such injuries seem infrequent. The enthusiasm for nail plate removal and nail bed repair is based largely on rationale and promoted by a few prominent advocates. There are no prospective, randomized controlled trials comparing no treatment with trephination or nail plate removal and nail bed repair. Most studies include a variable and wide range of injuries, including amputations. DIRECTIONS FOR FUTURE RESEARCH A large prospective cohort of patients with fingertip crush injuries and subungual hematoma but no
Ó 2015 ASSH
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Published by Elsevier, Inc. All rights reserved.
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laceration followed for at least 6 months (sufficient time for expected nail regrowth) could help establish the prevalence, type, and severity of nail deformity. Prospective, randomized control trials comparing treatments of large subungual hematomas with and without distal phalanx fractures would help determine if treatment is helpful and what treatment is best. The final nail appearance should be assessed by a trained observer not involved in care and blinded to treatment. We need a reliable rating of nail deformity. If research can establish the effectiveness of nail bed repair over natural healing, another line of research might address the technical aspects of nail bed repair. Nail bed repair is technically difficult. Using very small absorbable sutures under magnification to repair uneven, often complex, nail bed fissures (some associated with underlying fractures), is difficult. One would think that optimal equipment, lighting, assistance, and surgeon experience might be helpful, but these procedures are often performed by trainees in the emergency room. Treatment in the emergency department is likely more economical. It would be worthwhile to randomize patients to treatment in the emergency department and treatment in the operating room, comparing nail deformity and resource utilization. Similar studies could address the influence of surgeon experience on outcomes. Additionally, a study on techniques could address whether debridement of the laceration and the resultant increase in tension on the sutured nail bed fissure affects outcomes. A randomized trial comparing nail bed repair with and without excision of contused edges of the nail fissure would help determine the balance between repair of healthier tissue versus creating tension in the repair.
the distal phalanx treated with pinning, or a laceration with injury to the nail plate. We favor treatment in the emergency department, reserving treatment in the operating room for injuries with an unstable distal phalanx fracture that will be pinned. Our rationale for treatment in the emergency department is that ours is equipped with adequate lighting and instrumentation, and the procedure can be completed without a dedicated anesthesiologist and at a lower cost. No debridement of the nail bed is performed, because we believe even severely contused tissue will heal and excessive tension on the repair will lead to scarring. Radial incisions are made in the nail fold (perpendicular to the nail fold) to visualize the germinal matrix as needed. We prefer placing nonadherent gauze under the nail fold rather than replacing the nail because it avoids subungual fluid collection (which might harbor infection and cause masceration of the healing tissue) and it allows for direct assessment of the injury. REFERENCES 1. Gellman H. Fingertip-nail bed injuries in children: current concepts and controversies of treatment. J Craniofac Surg. 2009;20(4): 1033e1035. 2. Johnson M, Shuster S. Continuous formation of nail along the bed. Br J Dermatol. 1993;128(3):277e280. 3. Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg Am. 1999;24(6):1166e1170. 4. Zook EG. The perionychium: anatomy, physiology, and care of injuries. Clin Plast Surg. 1981;8(1):21e31. 5. Simon RR, Wolgin M. Subungual hematoma: association with occult laceration requiring repair. Am J Emerg Med. 1987;5(4):302e304. 6. Meek S, White M. Subungual hematomas: is simple trephining enough? J Accid Emerg Med. 1998;15(4):269e271. 7. Kleinert HE, Ashbell TS, Putcha SM, Kutz JE. The deformed finger nail, a frequent result of failure to repair nail bed injuries. J Trauma. 1967;7(2):177e190. 8. Zook EG, Guy RJ, Russell RC. A study of nail bed injuries: causes, treatment, and prognosis. J Hand Surg Am. 1984;9(2):247e252. 9. Hart RG, Kleinert HE. Fingertip and nail bed injuries. Emerg Med Clin North Am. 1993;11(3):755e765. 10. Lee DH, Mignemi ME, Crosby SN. Fingertip injuries: an update on management. J Am Acad Orthop Surg. 2013;21(12):756e766. 11. Strauss EJ, Weil WM, Jordan C, Paksimasima N. A prospective, randomized, controlled trial of 2-octylcyanoacrylate versus suture repair for nail bed injuries. J Hand Surg Am. 2008;33(2):250e253. 12. O’Shaughnessy M, McCann J, O’Connor TP, Condon KC. Nail regrowth in fingertip injuries. Ir Med J. 1990;83(4):136e137.
OUR CURRENT CONCEPTS FOR THIS PATIENT Even for subungual hematomas involving more than 60% of the visible nail plate, with or without a minimally displaced fracture of the distal phalanx, we favor trephination or no procedure when the nail plate is adherent to the nail bed and is without laceration. We favor nail plate removal and nail bed repair in the following circumstances: a proximal fracture that involves the germinal matrix, a displaced fracture of
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A prospective study of 52 children with subungual hematomas involving more than 25% of the visible nail plate found no difference in outcomes between nail trephination and nail bed, repair with both groups having only transient nail abnormalities.3 Zook8 reported 90% good to excellent results in nearly 300 nail bed injuries treated with nail plate removal and nail bed repair under loupe magnification using 7-0 chromic gut suture and reduction and pinning of unstable distal phalanx fractures. Worse outcomes were associated with crush and avulsion type injuries and the rare infection. There was no difference with nail replacement compared with no replacement of the nail. Strauss et al11 used 2-octyl cyanoacrylate (Dermabond; Ethicon, Inc, Summerville, NJ) to repair 18 nail beds and used suture to repair another 22 nail beds. The 2-octyl cyanoacrylate group had 15 excellent, 2 very good, and 1 poor result, and the suture repair group had 17 excellent, 4 very good, and 1 good results based on physician-evaluated cosmetic appearance. O’Shaughnessy et al12 compared 10 patients where the nail was replaced after nail bed repair with 54 patients where the nail bed was not replaced after repair. They found no significant difference in the appearance of the nail or the rate of re-growth, but crush injuries were worse in both groups. SHORTCOMINGS OF THE EVIDENCE The natural history of nail growth and nail deformity after crush injury and subungual hematoma is uncertain. Subungual hematomas are common, and associated fissures in the nail bed are common as well, but substantial nail deformities from such injuries seem infrequent. The enthusiasm for nail plate removal and nail bed repair is based largely on rationale and promoted by a few prominent advocates. There are no prospective, randomized controlled trials comparing no treatment with trephination or nail plate removal and nail bed repair. Most studies include a variable and wide range of injuries, including amputations. DIRECTIONS FOR FUTURE RESEARCH A large prospective cohort of patients with fingertip crush injuries and subungual hematoma but no
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
581
Evidence-Based Medicine
EVIDENCE-BASED MEDICINE
582
NAIL BED INJURY
Evidence-Based Medicine
laceration followed for at least 6 months (sufficient time for expected nail regrowth) could help establish the prevalence, type, and severity of nail deformity. Prospective, randomized control trials comparing treatments of large subungual hematomas with and without distal phalanx fractures would help determine if treatment is helpful and what treatment is best. The final nail appearance should be assessed by a trained observer not involved in care and blinded to treatment. We need a reliable rating of nail deformity. If research can establish the effectiveness of nail bed repair over natural healing, another line of research might address the technical aspects of nail bed repair. Nail bed repair is technically difficult. Using very small absorbable sutures under magnification to repair uneven, often complex, nail bed fissures (some associated with underlying fractures), is difficult. One would think that optimal equipment, lighting, assistance, and surgeon experience might be helpful, but these procedures are often performed by trainees in the emergency room. Treatment in the emergency department is likely more economical. It would be worthwhile to randomize patients to treatment in the emergency department and treatment in the operating room, comparing nail deformity and resource utilization. Similar studies could address the influence of surgeon experience on outcomes. Additionally, a study on techniques could address whether debridement of the laceration and the resultant increase in tension on the sutured nail bed fissure affects outcomes. A randomized trial comparing nail bed repair with and without excision of contused edges of the nail fissure would help determine the balance between repair of healthier tissue versus creating tension in the repair.
the distal phalanx treated with pinning, or a laceration with injury to the nail plate. We favor treatment in the emergency department, reserving treatment in the operating room for injuries with an unstable distal phalanx fracture that will be pinned. Our rationale for treatment in the emergency department is that ours is equipped with adequate lighting and instrumentation, and the procedure can be completed without a dedicated anesthesiologist and at a lower cost. No debridement of the nail bed is performed, because we believe even severely contused tissue will heal and excessive tension on the repair will lead to scarring. Radial incisions are made in the nail fold (perpendicular to the nail fold) to visualize the germinal matrix as needed. We prefer placing nonadherent gauze under the nail fold rather than replacing the nail because it avoids subungual fluid collection (which might harbor infection and cause masceration of the healing tissue) and it allows for direct assessment of the injury. REFERENCES 1. Gellman H. Fingertip-nail bed injuries in children: current concepts and controversies of treatment. J Craniofac Surg. 2009;20(4): 1033e1035. 2. Johnson M, Shuster S. Continuous formation of nail along the bed. Br J Dermatol. 1993;128(3):277e280. 3. Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg Am. 1999;24(6):1166e1170. 4. Zook EG. The perionychium: anatomy, physiology, and care of injuries. Clin Plast Surg. 1981;8(1):21e31. 5. Simon RR, Wolgin M. Subungual hematoma: association with occult laceration requiring repair. Am J Emerg Med. 1987;5(4):302e304. 6. Meek S, White M. Subungual hematomas: is simple trephining enough? J Accid Emerg Med. 1998;15(4):269e271. 7. Kleinert HE, Ashbell TS, Putcha SM, Kutz JE. The deformed finger nail, a frequent result of failure to repair nail bed injuries. J Trauma. 1967;7(2):177e190. 8. Zook EG, Guy RJ, Russell RC. A study of nail bed injuries: causes, treatment, and prognosis. J Hand Surg Am. 1984;9(2):247e252. 9. Hart RG, Kleinert HE. Fingertip and nail bed injuries. Emerg Med Clin North Am. 1993;11(3):755e765. 10. Lee DH, Mignemi ME, Crosby SN. Fingertip injuries: an update on management. J Am Acad Orthop Surg. 2013;21(12):756e766. 11. Strauss EJ, Weil WM, Jordan C, Paksimasima N. A prospective, randomized, controlled trial of 2-octylcyanoacrylate versus suture repair for nail bed injuries. J Hand Surg Am. 2008;33(2):250e253. 12. O’Shaughnessy M, McCann J, O’Connor TP, Condon KC. Nail regrowth in fingertip injuries. Ir Med J. 1990;83(4):136e137.
OUR CURRENT CONCEPTS FOR THIS PATIENT Even for subungual hematomas involving more than 60% of the visible nail plate, with or without a minimally displaced fracture of the distal phalanx, we favor trephination or no procedure when the nail plate is adherent to the nail bed and is without laceration. We favor nail plate removal and nail bed repair in the following circumstances: a proximal fracture that involves the germinal matrix, a displaced fracture of
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