Should you use a glue stick or needle and thread to repair Nail Bed Injuries?
A common injury in pediatrics (and the adult world) is nail injuries. Often these can be crush injuries (think of the last child you saw present after their fingers were crushed in a door) or trauma from some sort of sharp device or instrument. The standard approach if there is a suspicion of a nail bed laceration and/or avulsion is to remove the nail, repair any underlying laceration and then splint the eponychium either with the original nail itself or a substitute.
A functional nail is important for sensation and grasping items, and the cosmetic outcome is important for many patients and families. Therefore, the main goals of nail removal and repair are to:
- Facilitate evaluation of the nailbed, and treatment of any discovered wounds if necessary
- Promote cosmetic and functional healing of the affected finger
Once you have removed the nail you can assess the damage and determine how will you repair any lacerations you find before reattaching and splinting. The standard technique is to use rapid absorbing suture for repair of nail bed lacerations and then reattach the splint with 2 simple nonabsorbable sutures. However, what about using tissue adhesive (Dermabond©) for both steps? (Closing the Gap has an excellent overview of this wider topic of injuries and repair and they also link to this excellent write up at Academic Life in Emergency Medicine on how to use tissue adhesive to reattach the nail) Tissue adhesive has been extensively studied in both adult and pediatric populations and is widely viewed as a safe and reasonable option for many forms of laceration repair in children at other anatomical sites. The first description of tissue adhesive to reattach the nail was described here in 1997 with good results.
In 2008 a randomized controlled trial was performed by E. Strauss et. al. Adult patients with acute nail bed lacerations were randomized to two groups. One group used tissue adhesive and the other group used suture material for laceration repair AND nail splint fixation in both steps. Their outcome measures were cosmetic and functional appearance of the healed nail at a minimum of 4 months as evaluated by both a physician and the patient. Of note they noted no significant difference between the two groups regarding cosmesis and functionality as well as no significant increase in nail infections. Their study also noted a very significant difference in time of repair (9.5 minutes for tissue adhesive, 27.8 minutes for suture repair). This is potentially quite a significant difference when you are considering a the need for child life, pharmacologic anxiolysis and digital block for the squirmy pediatric patient in your busy ED. Noted limitations to this study would be the relatively small sample size and that the vast majority of their discussion relates to cosmesis, but little on how well tissue adhesive actually kept the nail splinted. Can these results be extrapolated to pediatric patients with nailed injuries?
Fortunately Langlois et. al has also since published a follow up study (of sorts) the following year regarding the use of tissue adhesive in pediatric patients. They performed a prospective trial using solely tissue adhesive for both nail bed repair and reattachment of the nail of 30 patients. While their sample size was small they had excellent reported results overall, no reported wound infections and overall satisfactory cosmetic and functional results. Again, this study, like the study by Strauss, has limited generalizability given it’s limited sample size and by being a purely prospective study without a control group.
While the data appears to be too limited in children to move fully to using tissue adhesive as the front line material for nail bed injury repair it is favorable in some respects – especially time to procedure completing and cosmesis. This illustrates, if anything, the need for larger studies to see if this technique can be generalized within the pediatric population and that it truly is not inferior to the time honored suture repair technique. The durability of the repair in the face of a slobbering toddler is paramount. Additionally, any patient in whom the repair could be compromised du to accidental manipulation should be splinted.
If time or the ability to use less sedation/anxiolysis is a major concern, tissue adhesive could be a very viable option in pediatric patients for nail bed repair. Watch out needle and thread, there’s a new glue stick in town.
Langlois; C. Thevenin-Lemoine; A. Rogier; M. Elkaim; K. Abelin-Genevois; R. Vialle “The use of 2-octylcyanoacrylate (Dermabond(®)) for the treatment of nail bed injuries in children: results of a prospective series of 30 patients.” J Child Orthop. 2010 Feb;4(1):61-5. doi: 10.1007/s11832-009-0218-1. Epub 2009
Strauss; W. Weil; C. Jordan; N. Paksima; “A Prospective, Randomized, Controlled Trial of 2-Octylcyanoacrylate Versus Suture Repair for Nail Bed Injuries” J Hand Surg. February 2008. 33A. Pp. 250-253, 2008.
Stanislas; M. Waldram; ‘Keep the nail plate on with Histoacryl.” Inj. Vol. 1997. 28:8, 507-508, 1997.
Reid; M. Duncan; “Interventions for treating fingertip entrapment injuries in children”. Ped Child Health. January 2016. 21.1. Pp. 27-28, 2016.
Lin. “Nailbed Inuries, Part II” https://lacerationrepair.com/anatomic-regions/nailbed-injuries-part-ii/ Accessed on 11/10/16
Rezaie; “Trick of the Trade: Nail Bed Repair with Tissue Adhesive Glue.” https://www.aliem.com/2014/trick-trade-nail-bed-repair-tissue-adhesive-glue/. Accessed on 11/10/16