Understanding the perionychium

Epidemiology and Outcome of Nailbed Injuries Managed in Children's Emergency Department: A 10-Year Single-Center Experience

BACKGROUND

Fingertip injuries are among the most common hand injuries in children and result in significant health, time, and a financial burden. Nailbed injuries constitute a large proportion of fingertip injuries and are frequent in children.

OBJECTIVES

This study aimed to examine the epidemiology, injury patterns, and treatment strategies implemented in patients with nailbed injuries between 0 and 18 years of age. We also wanted to identify various acute and chronic complications associated with nailbed injuries in these patients.

METHODS

This was a single-center retrospective study carried out on the data collected between October 1, 2009, and October 31, 2019.

RESULTS

We identified 457 patients with upper extremity nailbed injuries during the study period. Most children were male, accounting for 62.8% (287) of the patients. Door crush injuries (59.5%) resulted in the majority of the nailbed injuries. The commonest place of injury occurrence was home (46.4%), followed by playground (28.4%). The next most frequent areas were public areas (17.5%) and school (7.7%). Simple nailbed laceration with partial avulsion of the nail (44.4%) was the most common type of nailbed injury. Most nailbed injury repairs were done by the pediatric emergency doctor (72.2%). The predictors for the occurrence of complications after nailbed injury were the type of injury (stellate laceration and severe crushed nailbed injuries) and fracture of the distal phalanx. The predictors for the use of antibiotics after nailbed injury in our patients were the mechanism of injury (crushed in door, sports injury, and road traffic accident) and fracture of the distal phalanx. Age was found to be associated with subungual hematomas and avulsion, whereas female sex was found to be associated with crush injuries.

CONCLUSIONS

In this study, most patients (72.2%) had their nailbed injuries repaired by pediatric emergency doctors. The commonest mechanism of nailbed injury was door crush injuries. Increased awareness and education of the caregivers might help avoid these injuries because the injury mechanism in most of the patients is preventable. Partial nail avulsion with underlying simple laceration of the nailbed was the most frequent type of nailbed injury seen. The complications that were seen after nailbed injuries were fingertip sensitivity (5.3%), split nail deformity (5.3%), infection (3.9%), nonadherence of the nail plate (2%), and hook nail deformity (1%). The predictors for the occurrence of complications after nailbed injury were the type of injury (stellate laceration and severe crushed nailbed injuries) and fracture of the distal phalanx. The predictors for the use of antibiotics after nailbed injury in our patients were the mechanism of injury (crushed in door, sports injury, and road traffic accident) and fracture of the distal phalanx. Age was found to be associated with subungual hematomas and avulsion, whereas female sex was found to be associated with crush injuries. Possessing a robust understanding of the mechanism of injury and the underlying anatomy with a detailed assessment of the nailbed injury is of paramount importance in the management of these patients. An initial thorough assessment and meticulous repair of the nailbed injuries will result in good outcomes with overall few complications.

Is Fixing Pediatric Nail Bed Injuries With Medical Adhesives as Effective as Suturing?: A Review of the Literature

OBJECTIVES

Nail bed injuries are common in children, with nail bed damage accounting for 15% to 24% of fingertip injuries. Our objective was to see whether medical adhesives, the cyanoacrylates including Histoacryl and Dermabond, could be used to fix nail bed lacerations as opposed to doing a primary repair with sutures, thus potentially being a quicker method for repair in the emergency department for these injuries.

METHODS

We conducted a literature review using the search engines MEDLINE, PubMed, Web of Science, and Google Scholar, and the references within these articles were also integrated. All articles in English were searched. Search terms included "nail bed repair," "nail bed laceration repair," and "cyanoacrylate."

RESULTS

A total of 6 articles were found using the previously mentioned search terms. Four articles using 2-octyl cyanoacrylate or Dermabond for the repair of nail bed injuries were found, with 2 additional articles describing the use of Histoacryl-n-butyl-2-cyanoacrylate-for nail injury repairs.

CONCLUSIONS

The 6 articles discussed in this article include approximately 118 patients' worth of data including a mix of adult and pediatric patients. Despite the small numbers and variety of types of study, it is encouraging that there are so many positive results. Cryoacrylates such as Dermabond or Histoacryl maybe useful to assist with nail injuries in children. Therefore, we feel that using a medical adhesive is as effective as suturing nail bed injuries in children.

Polypropylene prosthesis for the treatment of fingertip injuries. Description of surgical technique and results

Objective

Report the results of treatment of fingertip injuries and describe this reproducible and low cost surgical technique, which utilizes a polypropylene prosthesis that temporarily replaces the nail and is placed on the area of injury, providing protection and encouragement for healing by secondary intention.

Method

This study evaluated 22 patients with traumatic injuries of the fingertips in the period from January 2012 to December 2015. All procedures were performed by the same surgeon. The mean postoperative follow-up was 13 months, with a minimum follow-up of six months. For all statistical inferences, a p-value of 0.05 was considered. The software used was SPSS version 21.0 for Windows.

Results

There were no cases of complications related to the polypropylene device. There was no significant difference between static two-point discrimination and age, between discrimination and time between injury and surgery, or between discrimination and time to follow-up. The authors used a table of scores that includes three factors proposed by Jefferson for a better evaluation of the results. 72.7% (16 cases) of patients had good results, 22.7% (five cases) fair results, and only 4.5% (one case) poor result.

Conclusion

This study presented a new technique for finger tip lesions, simple and easily reproducible, with satisfactory results and low complication rates.

Management of uncomplicated nail bed lacerations presenting to a children's emergency department

OBJECTIVE

This study examined the mechanisms of injury and the pattern of care for children who presented to the emergency department with uncomplicated nail bed lacerations.

METHODS

A retrospective chart review was conducted from January 2004 to December 2007 for all children younger than 18 years who presented to a tertiary children's hospital with an uncomplicated nail bed laceration.

RESULTS

There were 84 cases of uncomplicated nail bed injuries for more than a 4-year period. Sixty percent of the subjects were males. The mean age was 5.3 (SD, 4.1) years. Most injuries occurred at home (58%), and the most common mechanism of injury was a door (67%). Approximately 40% of patients were treated by emergency physicians. There was no significant difference in acute and chronic complications or in the length of stay in the emergency department, between patients treated by emergency physicians and by plastic surgeons.

CONCLUSIONS

Most nail bed injuries in children occur at home, and the door seems to be the major mechanism of injury. Approximately 57% of these are children younger than 5 years. Only 42% of uncomplicated nail bed lacerations are treated by emergency physicians, yet there is no significant difference in outcomes between plastic surgeons and emergency physicians. Our study suggests that there is a role in public education for primary prevention, and with proper training, pediatric emergency physicians can treat uncomplicated nail bed lacerations.