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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?
Irrigation and debridement with alumafoam placement and immobilization
Irrigation and debridement followed by percutaneous pinning and immobilization
Irrigation and debridement followed by reduction, nail bed repair and immobilization
Betadine soaks at home three times daily with intermittent alumafoam splint placement and immobilization
Alumafoam splint placement and immobilization
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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.
Inglefield CJ, D'Arcangelo M, Kolhe PS.
J Hand Surg Br. 1995 Apr;20(2):258-61. PMID: 7797986 (Link to Abstract)
J Am Acad Orthop Surg. 1996 Jan;4(1):84-92. PMID: 10795040 (Link to Abstract)
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Repair of a nailbed injury with 2-octylcyanoacrylate (Dermabond) provides what distinct advantage over standard suture repair?
Better ultimate cosmesis
Better functional outcome
Less pain at follow up
Lower infection rate
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.
Answer 1,2,4,5: There is no difference in these outcomes when comparing 2-octylcyanoacrylate (Dermabond) versus suture repair
Strauss EJ, Weil WM, Jordan C, Paksima N
J Hand Surg Am. 2008 Feb;33(2):250-3. PMID: 18294549 (Link to Abstract)
Richards AM, Crick A, Cole RP.
Plast Reconstr Surg. 1999 Jun;103(7):1983-5. PMID: 10359264 (Link to Abstract)
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