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

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

2016-11-11T19:21:02+00:00

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)

1.
Strauss E, Weil W, Jordan C, Paksima N. A prospective, randomized, controlled trial of 2-octylcyanoacrylate versus suture repair for nail bed injuries. J Hand Surg Am. 2008;33(2):250-253. [PubMed]
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
  • William Green

    Great tip, this has been my preferred method of nail bed repair for several years. One caution- it is important to achieve and maintain complete hemostasis during the application and drying period of the tissue adhesive. Otherwise you end up with a messy mix of blood and tissue adhesive which can delay healing and increase the rate of complications. It wasn’t mentioned in the abstract, but all patients treated (both sutures and tissue adhesive) had a tourniquet applied during the procedure. We use the T-RING tourniquet in our ED, you can apply it without causing further injury to the delicate nail bed tissue, which may occur with methods that need to be rolled onto the digit.

    Last comment – when reading the above description, it was initially clear if the Trick of the Trade was securing the nail in place, or repairing the nail bed.

    • William Green

      One more comment regarding finger injuries and the use of tissue adhesives – tissue adhesives have been called “the ideal closure method” for uncomplicated finger lacerations less than 2.5cm (Audio-Digest Emergency Medicine, Dec 2009). Better than 80% of finger lacs meet this criteria. I’ll use Dermabond and adhesive strips (again – critical to maintain hemostasis during repair and drying period) , then put the patient in a bandage or splint that limits flexion and extension. I think its crazy that most of these lacerations are getting sutured – studies show putting in sutures on finger lacerations takes longer, increases pain and the rate of infection, and doesn’t improve the clinical outcome. Sutures also require follow up for removal, which is costly (a few hundred dollars on average) and inconvenient for the patient.

      • Salim R. Rezaie

        Hello William,
        Thank you for your comments. I certainly think this is the way to go.

        Salim

      • aj

        I seem to remember reading something recently about not doing anything at all for nailbed lacs. Maybe you don’t have to do anything? Maybe just trephinate for patient comfort. I guess the concern is destroying the nail, but does anyone know if that really happens a lot. What I’d the real risk here?

        • William Green, MD FACEP

          Hi AJ,

          You are correct – many feel that the nail should only be removed for repair if it is already completely or partially avulsed. The following review of these injuries is from EMedhome: “In the past, for hematomas involving more than 50% of the nail bed, many physicians recommended removal of the nail and repair of any underlying laceration of the nail bed, since the incidence of underlying lacerations was found to be quite high (especially in association with underlying tuft fractures). However, in a study by Seaberg et al., involving 45 patients who presented to the emergency room with subungual hematomas, simple nail trephination resulted in healing without any nail deformities or other complications in all the patients. Thus, simple nail trephination with the use of a handheld portable cautery is recommended for most subungual hematomas. A prospective study of 52 patients with nail-bed injuries, reported by Roser and Gellman, showed that the outcomes were similar with nail removal and nail trephination, and there were significant cost savings associated with the more conservative care. Nail removal should probably be reserved for subungual hematomas that are associated with disruption of the nail or surrounding nail folds.

    • Salim R. Rezaie

      Hello William. I have corrected the post to read more clearly, but tissue adhesive can be used for both the nailbed injury and holding the nail in place. Instead of suturing the nailbed injury and then the nail to hold it into place. I hope this clears up the post.

      Salim

      • William Green, MD FACEP

        Hi Salim. I just reread, looks great. Thanks again for the info.

        WIlliam

    • Michelle Lin

      Thanks William. Great tips all around. Love using tissue adhesives for both parts of nail bed injury repair (laceration repair, holding nail back in place). Fixed the text a bit more tonight to clarify these points. Thanks for feedback.

      • William Green, MD FACEP

        Hi Michelle, thanks for the note and the added clarification.

        William

  • Hi Salim
    I found this post is confusing – the pictures show glue being used to secure the replaced nail, yet the paper seems to talk about repair of nail bed injuries – two different things.
    Chris

    • Salim R. Rezaie

      Hey Chris,
      Yes the adhesive can actually be used for both. I have fixed some of the wording of the post to make that more clear. It is the ideal agent for both the nailbed injury and holding the nail in place….as in neither requiring suture. Hope that clears it up, and let me know if wording still not ok.

      Salim

    • Michelle Lin

      Good call. Made a few more edits to clarify. Post-publication peer review 1, pre-publication peer review 0.

  • Namer

    Any concerns for use on a diabetic patient foot nail?

    Thanks

    • Michelle Lin

      Every nail bed repair is different. Being purely a diabetic shouldn’t be a contraindication. If the nail bed can be cleaned well, the wound edges are approximate-able, and the patient can careful wound checks especially if there’s distal neuropathy, it would seem to be ok. Need to factor in wound characteristics, overall patient health, and social situation. Hope that helps. Good luck!

      • Namer

        Thank you so much! It helps a lot

  • Salim, excellent writeup and information. My one comment is related to the digital block technique you describe. In 2010 my colleagues and I published a paper on the modified transthecal digital nerve block in children. One stick and 94% success rate. Here is the pubmed link http://www.ncbi.nlm.nih.gov/pubmed/20179662. I’d be happy to share the full paper if you’d like it.