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Nail Bed RepairPatients with fingertip injuries involving the nail bed typically present to the emergency department and require meticulous repair of the nail bed to prevent long-term cosmetic and functional disability. There are several methods to repair nail beds, typically involving absorbable suture, but maybe there is a faster way with similar cosmetic and functional outcomes. 

Case

A 28 year old, left handed female comes to your ED with a chief complaint of having her left thumb slammed in a car door.  She has no past medical problems or surgeries and no allergies to medications. Her injury is shown below:

IMG_4033

 

The patients finger was anesthetized with a 3 point ring block at the base of the thumb, and the nail was then removed.  There was also a small nail bed laceration that did require some absorbable sutures. After repair of the nail bed laceration, an 18 gauge needle was used to place 4 holes in the nail itself so that the The nail could be reinserted and secured with 4-0 vicryl sutures. But could there have been an alternative approach?

ThumbAndNail

Trick of the Trade: Nail bed repair with tissue adhesive glue

Instead of sutures, tissue adhesive can be used for two purposes:

  1. Repairing a nail bed laceration
  2. Holding the nail in place

The picture below shows an example of how the nail can be slid back into place and secured with glue.

ToenailDermabond2sm

Evidence behind the trick:

Dermabond for nail bed laceration repair [1]

 

What they did

  • Prospective comparison of 2-octylcyanoacrylate (Dermabond; Ethicon Inc, Somerville, NJ) vs standard suture repair using 6-0 chromic
  • 40 consecutive patients

Outcomes

  • Time to repair
  • Cosmetic and functional outcomes at 1, 3, and 6 months

Results

  • Time to repair: 9.5 min (Dermabond) vs 27.8 min (standard suture repair)
  • Infection rate: 1 patient (Dermabond) vs 0 patients (standard suture repair)
  • No statistical difference in physician judged cosmesis, patient perceived cosmesis, or patient perceived functional outcomes

Trick of the Trade: Nail Bed Repair With Dermabond

Limitations:

  • Repairs were performed by orthopedic residents and not emergency medicine residents
  • Small sample size was a major issue: Only allowed for statistically significant difference in time of repair
  • Dominant hand injury was < 50% of cases in both groups which may have biased functional scores
  • There was a disproportionate number of stellate lacerations in the standard suture repair group (6) vs Dermabond group (3), which may have biased the results.

Conclusion: Dermabond is an efficient and effective alternative to sutures in nail bed injuries.

Take Home Message

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.

 

Post updated May 26, 2014 (22:47 PST)

 

References

  1. E.J. Strauss, W.M. Weil, C. Jordan, and N. Paksima, "A prospective, randomized, controlled trial of 2-octylcyanoacrylate versus suture repair for nail bed injuries.", The Journal of hand surgery, 2008. http://www.ncbi.nlm.nih.gov/pubmed/18294549
Salim Rezaie, MD

Salim Rezaie, MD

ALiEM Associate Editor
Clinical Assistant Professor of EM and IM
University of Texas Health Science Center at San Antonio
Founder, Editor, Author of R.E.B.E.L. EM and REBEL Reviews