|
http://upload.orthobullets.com/topic/6109/images/nail avulsion.jpg
http://upload.orthobullets.com/topic/6109/images/fingertip.jpg
http://upload.orthobullets.com/topic/6109/images/nailbedfxapx1600.jpg
http://upload.orthobullets.com/topic/6109/images/tx of subungual hematoma.jpg
http://upload.orthobullets.com/topic/6109/images/nail.jpg
Introduction
  • Nail bed injuries are the result of direct trauma to the fingertip. Injury types include 
    • subungual hematoma (details below)
    • nail bed laceration 
    • nail bed avulsion 
  • Epidemiology
    • nail bed injuries are included under the umbrella of fingertip injuries
      • finger tip injuries are the most common hand injuries seen in the hospital emergency department 
  • Pathophysiology
    • mechanisms of injury include
      • crushing fingertip between two objects
      • catching finger in a closing door
      • saw injury 
      • snowblower injury
      • direct blow from a hammer
  • Associated conditions
    • DIP fractures or dislocations 
  • Prognosis
    • early treatment of acute injuries results in the best outcomes with minimal morbidity
Anatomy
  • Nailbed and surrounding tissue 
    • perionychium
      • nail
      • nailbed
      • surrounding skin
    • paronychium
      • lateral nail folds
    • hyponychium
      • skin distal distal and palmar to the nail
    • eponychium
      • dorsal nail fold
      • proximal to nail fold
    • lunula
      • white part of the proximal nail
    • matrix
      • sterile
        • soft tissue deep to nail
        • distal to lunula
        • adheres to nail
      • germinal 
        • soft tissue deep to nail
        • proximal to sterile matrix
        • responsible for most of nail development
        • insertion of extensor tendon is approximately 1.2 to 1.4 mm proximal to germinal matrix
Presentation
  • Symptoms
    • pain
  • Physical exam
    • examine for subungual hematoma
    • inspect nail integrity
Imaging
  • Radiographs
    • recommended
      • AP, lateral and oblique of finger  
        • to rule out fracture of distal phalanx 
Subungual Hematoma
  • Most commonly caused by a crushing-type injury 
    • causes bleeding beneath nail
  • Treatment 
    • drainage of hematoma by perforation 
      • indications
        • less than 50% of nail involved
      • techniques
        • puncture nail using sterile needle
        • electrocautery to perforate nail
    • nail removal, D&I, nail bed repair
      • indications
        • > 50 % nail involved
      • technique
        • nail bed repair (see techniques)
Nail Bed Lacerations
  • Laceration of the nail and underlying nail bed
    • usually present with the nail intact and a subungual hematoma greater than 50% of nail surface area
  • Treatment
    • nail removal with D&I, nail bed repair
      • indications
        • most cases 
      • modalities
        • tetanus and antibiotic prophylaxis
 
Avulsion Injuries
  • Avulsion of nail and portion of underlying nail bed 
  • Mechanism
    • usually caused by higher energy injuries  
  • Associated conditions
    • commonly associated with other injuries including
      • distal phalanx fracture
        • if present reduction is advocated 
  • Treatment
    • nail removal, nail bed repair, +/- fx fixation 
      • indications
        • avulsion injury with minimal or no loss of nail matrix, with or without fracture 
      • technique
        • always give tetanus and antibiotics
        • fracture fixation depends on fracture type
    • nail removal, nail bed repair, split thickness graft vs. nail matrix transfer, +/- fx fixation
      • indications
        • avulsion or crush injury with significant loss of nail matrix
      • technique
        • always give tetanus and antibiotics
        • nail matrix transfer from adjacent injured finger or nail matrix transfer from second toe
        • fracture fixation depends on fracture type
Techniques
  • Nail bed repair
    • nail removal
      • soak nail in Betadine while repairing nail bed
    • nail bed repair
      • repair nail bed with 6-0 or smaller absorbable suture
      • RCT has demonstrated quicker repair time using 2-octylcyanoacrylate (Dermabond) instead of suture with comparable cosmetic and functional results 
    • splint eponychial fold
      • splint eponychial fold with original nail, aluminum, or non-adherent gauze
Complications
  •  Hook nail 
    • caused by advancement of the matrix to obtain coverage without adequate bony support 
      • Treatment
        • remove nail and trim matrix to level of bone 
  • Split nail 
    • caused by scarring of the matrix following injury to nail bed
      • Treatment
        • excise scar tissue and replace nail matrix 
          • graft may be needed
 

Please rate topic.

Average 4.2 of 23 Ratings

Questions (2)

(OBQ11.74) A 7-year-old boy sustains a ring finger injury after falling from his bike. The fingernail has been torn transversely beneath the eponychium and the surgeon has removed the nail as shown in Figure A. Radiographs are shown in Figure B. What is the next best step in management? Review Topic

QID:3497
FIGURES:
1

Irrigation and debridement with alumafoam placement and immobilization

3%

(57/2259)

2

Irrigation and debridement followed by percutaneous pinning and immobilization

9%

(214/2259)

3

Irrigation and debridement followed by reduction, nail bed repair and immobilization

87%

(1956/2259)

4

Betadine soaks at home three times daily with intermittent alumafoam splint placement and immobilization

0%

(10/2259)

5

Alumafoam splint placement and immobilization

1%

(12/2259)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

The clinical presentation is consistent with a physeal separation and a nail bed injury. This is also called a Seymour fracture which is a juxta-epiphyseal fracture of the distal phalanx. Treatment of a nail bed avulsion and physeal separation is irrigation and debridement, physeal reduction, nail bed repair and immobilization. The primary goals are to achieve a stable, viable nail and good cosmetic results.

Inglefield at al retrospectively reviewed 19 children with 22 nail bed injuries. Early operative repair led to good to excellent results in 91% of patients. They concluded that repair of the nail bed at the time of injury is superior to secondary correction.

Fassler reviewed fingertip injuries, providing recommendations for treatment based on degree of soft tissue loss, bone exposure, feasibility for flap coverage and the presence or absence of mitigating systemic conditions. He also concluded that the outcome of nail bed injuries is dependent on the severity of injury to the germinal matrix.

Illustration A shows the makeup of the terminal phalanx. Illustration B and C show a Seymour Fracture before and after irrigation and debridement and reduction.

ILLUSTRATIONS:

Please rate question.

Average 3.0 of 17 Ratings

Question COMMENTS (3)

(OBQ09.14) Repair of a nailbed injury with 2-octylcyanoacrylate (Dermabond) provides what distinct advantage over standard suture repair? Review Topic

QID:2827
1

Better ultimate cosmesis

6%

(102/1799)

2

Better functional outcome

2%

(43/1799)

3

Faster procedure

86%

(1542/1799)

4

Less pain at follow up

3%

(45/1799)

5

Lower infection rate

3%

(61/1799)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

Octylcyanoacrylate (Dermabond) has been found to be a viable method in nailbed repair, and has the advantage of being a faster procedure.

Strauss et al performed a level 1 randomized trial of 2-octylcyanoacrylate (Dermabond) versus suture repair of nailbed injuries. They found the only significant difference was that 2-octylcyanoacrylate had a shorter procedure time. All other indices were similar.

Richards et al provide a description of their technique using dermabond to secure the nail following a nailbed repair. They found good results with no complications in their cohort of 22 patients, and recommend it as a technique.

Illustration A shows a nail bed bed repair.

Incorrect Answers
Answer 1,2,4,5: There is no difference in these outcomes when comparing 2-octylcyanoacrylate (Dermabond) versus suture repair

ILLUSTRATIONS:

Please rate question.

Average 3.0 of 20 Ratings

Question COMMENTS (0)
GROUPS (1)
EVIDENCE & REFERENCES (4)
Topic COMMENTS (7)
Private Note