Patients 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.
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:
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?
Trick of the Trade: Nail bed repair with tissue adhesive glue
Instead of sutures, tissue adhesive can be used for two purposes:
- Repairing a nail bed laceration
- 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.
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
- Time to repair
- Cosmetic and functional outcomes at 1, 3, and 6 months
- 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
- 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)