20 EMN I October 2010 Evaluation and Treatment of InFocus Subungual

By James R. Roberts, MD

Author Credentials Finan- cial Disclosure: James R. Roberts, MD, is the Chair- man of the Department of Emergency Medicine and the Director of the Divi- sion of Toxicology at Mercy Catholic Medical Center, and a Professor of Emergency Medicine and Toxicology at the Drexel University College of Medicine, both in Philadelphia. Dr. Roberts has disclosed that he is a member of the Speakers Bureau for Merck Pharmaceuticals. He and all other faculty and staff in a position to 12 control the content of this CME activity have disclosed that they and their spouses/life partners (if any) have no fi- nancial relationships with, or financial interests in, any commercial companies pertaining to this educational activity.

Learning Objectives: After participat- ing in this activity, the physician should be better able to: 1. Formulate a plan to identify subun- gual that require simple trephination vs. nail removal. 2. Select the correct method of provid- ing nail trephination. 3. Predict the need for prophylactic an- tibiotics after hematoma evacuation. 5

mergency physicians frequently deal with patients who have suf- Efered trauma to the digits. This month’s column begins a series of discus- sions on a rational approach to fingertip problems by reviewing the ubiquitous subungual hematoma (SUH). SUHs are rather common, and cause incapacitating and throbbing pain, prompting the hardiest of souls to seek relief. Even narcotics may fail to relieve the pain produced by an ex- panding subungual hematoma as it compresses the sensitive nailbed so some method to release the pressure is usually required, and is usually imme- 6 7 diately curative. Few randomized con- trolled studies have critically evaluated therapeutic modalities, but clinical practice has identified the salient is- seasoned physicians are not cognizant Treatment of Subungual sues. Treatment recommendations Part 1 in a Series of all the issues. Hematomas with vary, and unsubstantiated clinical After reading this article, emergency Nail Trephination: dogma and waffling recommendations care. The key to a successful outcome physicians should be better able to A Prospective Study are extant. of any fingertip is to know when identify which subungual hematomas Seaberg DC, et al SUH is usually not a digit-threaten- to be conservative and when to be ag- require simple nail trephination vs. nail Am J Emerg Med ing injury, and rarely is even a cos- gressive. House staff usually learns removal, select the correct method of 1991;9(3):209 metic concern. But SUH is usually from on-the-job experience. Some providing nail trephination, and predict treated in the ED, and the emergency continue to repeat the mistakes of a the need for prophylactic antibiotics af- This nicely done sentinel study was physician should be an expert in its misinformed mentor because even ter hematoma evacuation. designed to determine if simple nail InFocus October 2010 I EMN 21

trephination alone would adequately fracture did not exclude patients from associated fracture. Although most pa- of the size of the SUH or the presence treat uncomplicated SUH without the protocol. tients with underlying fractures had a of an underlying phalanx fracture. producing or fostering associated The subjects were 3 to 60 years old. greater than 50 percent hematoma, The authors question the need for cosmetic or infectious complica- All underwent radiographic analysis, there was no close correlation be- routine radiographs in all cases, and tions. A subsequent ebidence-based and were treated with electrocautery tween the size of the hematoma and conclude that patients with uncompli- literature review (Emerg Med J trephination and expression of the the presence of a fracture. There were cated SUH will have excellent results 2003;20[1]:65) reached the same con- subungual blood. Antibiotics were not no complications directly related to with simple nail trephination without clusions. prescribed. Postoperative treatment the trephination, and there were no removal of the nail or suturing of the nailbed. This conclusion is contrary to other authors who suggest routine re- moval of a nail to meticulously repair nailbed lacerations. The authors em- phasize that their study examined only cases where the nail and nail margins were completely intact, and their con- clusions may not be applicable to ex- tensive crush or complex nail disruptions. They also believe an elec- trocautery provides the most ideal method for rapid and painless trephina- tion. If a fracture is present, routine pro- tective extension splints also are suggested. There appears to be no role for routine antibiotic coverage, even if 3 4 the phalanx is fractured and the nail has been trephined.

COMMENT: It is certainly undesirable 1. There is no SUH from this nail injury, but because 5. Replace the nail under the cuticle and secure it for any patient to end up with a per- the lateral nail margin and nailbed are obviously with lateral sutures. Do not suture through the ger- manently deformed nail, and major lacerated, they should be repaired. The nail has to minal matrix. As an option, drill a hole through the fingertip injuries require a cautious ap- be at least partially removed to accomplish this. replaced nail so any new bleeding will drain. Be proach. While the burly construction Don’t remove the entire nail, just enough to ex- sure to remove the tourniquet before applying any worker may not worry about a funky pose the injured nailbed. Do not avulse the base dressing. In about two to three weeks, the new nail fingertip, a woman showing off her en- of the nail, and preserve the germinal matrix so a gagement ring will. It’s clear, however, new nail will grow normally and cover the lacer- will begin to push out the replaced nail that was that some physicians are truly in a ated bed. used as a splint and dressing. Then you can re- move the sutures, and the replaced nail will fall off, clinical fog when it comes to evaluat- 2. This patient’s fingertip was smashed in a car door, a exposing the repaired nailbed. Cover the nailbed ing and treating SUH. Because of this very common injury that avulsed the nail at the base with a nonadherent dressing. It will take many study and others, most EPs are en- by flexion, and produced a nailbed laceration and weeks (six to eight) for the new nail to completely lightened, and opt for the conservative SUH. This nail should be removed and the nail re- cover the nailbed. simple trephination of even a total paired. SUH when the nail is intact. Hopefully the days are gone when SUH prompts 6. This may seem like a simple SUH, but blood under 3. To remove the nail, use small scissors to tease routine nail removal in search of the the cuticle (arrows) is a tipoff that the base of the the nail away from the nailbed. This will con- nefarious nailbed laceration that re- nail is likely avulsed, allowing blood from the vince you how tenacious the bond is. There is no quires meticulous suturing, repeat vis- nailbed laceration to collect between the skin and cutting involved. Hold the scissors horizontally in its, and a bare nailbed for weeks. base of the avulsed nail, which is now sitting on the plane between the bed and undersurface of Although most EPs approach SUH the nail. Gently spread as the instrument is ad- top of the cuticle. Swelling prohibits this from be- with that philosophy and simply vanced, avoiding further nailbed injury. Note that ing readily appreciated. The nail should be reposi- trephine the nail, it’s easy to get side- a tourniquet is used anytime the distal is tioned into its germinal matrix, and it may take tracked with aggressive nail removal repaired. Keep the removed nail to use as a hold and grow. dressing. and fancy nailbed repairs after a cur- sory reading of the hand surgery litera- 7. To accomplish repair of the injury in Photo 6, first 4. To obtain a clean field without annoying drapes, use ture. An SUH is clearly emergency the SUH is totally drained with simple trephina- a glove on the patient’s hand. Meticulously repair medicine turf, and hand surgeons only the nailbed with 6-0 (always use absorbable) su- tion. This avulsed nail may be manipulated back see these minor injuries when there are tures. The goal is to produce an anatomically per- into the germinal matrix with a hemostat (longitu- later complications. Other discussions fect nailbed to avoid ridges or nail deformities as dinal traction, pressure over the proximal nail of fingernail injuries can be found. (J the new nail grows back. base), avoiding total nail removal. Trauma 1967;7[2]:177; Hand Clin 1990;6[1]:37; Orthop Clin North Am James R. Roberts, MD 1992;23[1]:149; Emerg Med Clin North Am 1992;10[4]:801). Over two years, 48 ED patients with included splinting of fractures in cases of soft tissue , os- Impressively, and despite much un- SUH entered the study. Patients were extension for one week. Patients were teomyelitis, or permanent significant referenced paranoia about SUH, there excluded if they had disruption of the followed for at least six months after nail deformity. A few patients initially were no signs of permanent nail defor- fingernail itself, if the nail were loose, the injury for evaluation of deformi- had ridges in the nail at the site of mities in any patient in this study. Only the nail border violated, or previous nail ties, dysfunction, or signs of infection. trauma, but these had grown out, and 48 patients were studied, but because deformities existed, leaving only pa- The size of the hematoma was rated the nails appeared normal after three my waiting room is not filled with fin- tients with a closed hematoma, an intact relative to the nail surface area. The months. It took an average of four gers permanently deformed by this nail, and without external skin lacera- SUH involved more than 50 percent months for a new nail to grow follow- everyday injury, I am convinced that the tion or nail disruption or avulsion. Im- of the nail surface in more than half of ing trephination. Importantly, these ex- authors’ conclusions are valid. The lack portantly, an underlying distal phalanx the patients while 30 percent had an cellent results were achieved regardless Continued on next page 22 EMN I October 2010 InFocus

SUBUNGUAL HEMATOMA long the pain would persist. Usually a The ED Approach to Subungual fracture can be ruled out by mecha- Continued from previous page nism, and if there is no tenderness Hematoma when longitudinally compressing the of infectious complications, particularly fingertip or carefully palpating the dis- in patients with underlying fractures, is tal fat pad. Displaced phalanx frac- I also comforting. Although some physi- Data and clinical experience support simple nail trephination in all pa- tures should always be reduced. The cians routinely prescribe antibiotics tients with SUH when the fingernail is intact, and can serve as a splint for history usually gives you a clue. A following trephination when there is a any underlying nailbed laceration. This is appropriate regardless of the fracture is unlikely if the fingertip tuft fracture, reasoning that these are size of the hematoma or the presence of a tuft fracture. were lightly tapped by a hammer, but compound fractures after drainage, more likely if the digit was slammed I there are absolutely no data to support Removing the nail to assess the integrity of the nailbed or to provide a in a car door. The presence or absence this protocol and credible data against field for surgical repair of the nailbed is unnecessarily aggressive. One of an underlying crack in the distal the need for them. can order x-rays dictated by the individual situation. phalanx is of no importance to initial Simply stated, freely draining therapy. Laborers, typists, or musi- I nailbed hematomas do not get infected, Absent other significant fingertip injuries and if the nail and nail margin is cians may require an x-ray because and there is no evidence that prophy- intact, trephining gives a good cosmetic and functional result. fractures may mandate light duty or lactic antibiotics are required. I believe time off from work because of pain. A I one is on firm ground by withholding Adequate holes should be made in the nail to ensure complete and con- computer operator needs to know if antibiotics post-trephination of an un- tinual drainage. he has a fractured tuft. A documented complicated SUH, even with an under- fracture may mean the difference be- I lying fracture. Many hand surgeons Routine antibiotic coverage is unnecessary, even if there is a tuft fracture. tween a few days and weeks of dis- reflexively suggest prophylactic antibi- ability compensation. I otics, however. While antibiotics have If the nail is loose or split, or the laceration extends past the nail margin, Although no one disagrees that an never been a proven indication for hand the nail can be removed, the nailbed laceration repaired (always use ab- SUH requires trephination, there are a lacerations in general (Emerg Med J sorbable sutures), and the nail reapplied as a dressing. variety of personal preferences for the 2007;24[3]:218), there is some mystique trephination device and variations on I that all injured hands leave the ED with Be careful to recognize a mallet finger injury (rupture of the extensor ten- the actual procedure. The goal is to an antibiotic prescription. I have never don) and proximal nail avulsion, manifested by blood under the cuticle. provide a large enough hole for imme- seen osteomyelitis from an SUH, al- Both require additional intervention, such as prolonged splinting or repo- diate and continued drainage. I find it though it’s theoretically possible. In a sitioning of the nail respectively. All displaced fractures should be reduced more desirable and easier to obtain related scenario, numerous studies sug- and splinted as appropriate. proper drainage after a digital block gest no antibiotic coverage for other with long-acting bupivacaine. I’ll agree types of fingertip injuries, even those that the procedure can be done rela- with partial , exposed (Am J Emerg Med 1987;5[4]:302.) The The nailbed certainly must be tively painlessly if one gently uses the bone, or open tuft fractures. (Ann fingernail was removed to check for lacerated if an SUH is present, and the electrocautery, being careful not to ex- Emerg Med 1983;12[6]:358.) I would be the presence of a “reparable lacera- hematoma is merely the consequence ert downward pressure on the nailbed. slightly tempted to use three to five tion” in patients with an SUH greater of physical disruption to highly vascu- If a cautery is used, a large hole (3-4 days of post-trephination antibiotics for than one-fourth of the nailbed. By to- larized tissue. The contention that all mm) or multiple drainage holes should a gnarly macerated tip, suspicion of day’s standards, that is not indicated. nailbed lacerations must be meticu- be placed. A single small hole may nascent infection, an underlying frac- Clearly, large hematomas were associ- lously approximated to avoid future close and the hematoma can reform. ture in immunocompromised patients, ated with a nailbed laceration, but so nail cosmetic abnormalities is, how- Twirling an 18-gauge needle between or for those with peripheral vascular what? They discovered that 60 percent ever, unproven. I believe this recom- the thumb and forefinger is another disease. Nonetheless, it seems certain of patients with an SUH greater than mendation is clearly disproven by popular method to put a hold in the that routine antibiotics are overkill in half of the nail had a “laceration re- clinical experience, supplemented by nail. the garden-variety SUH. Tetanus toxoid quiring repair.” The incidence of repara- literature. The intact nail is an ideal I usually opt for the large paper clip is a good idea, but I could find no cases ble lacerations rose to 95 percent splint that provides integrity to the ma- (cheap and disposable) and butane of tetanus from nail trephination. when there was an associated frac- trix, and ensures close approximation lighter approach. Be sure to hold the In a related earlier and frequently ture. Patients were not followed for of any laceration. One need only try to heated paper clip with a hemostat. quoted study, Simon and Wolgin evalu- cosmetic results, and the authors did remove a fingernail to be convinced Two or three tries are usually needed ated 47 adult patients with an SUH to not define “reparable.’’ I assume any that the nail is normally firmly at- before the nail is punctured. One gen- determine the association between the obvious disruption of the bed was con- tached to the nailbed. Such stabiliza- erous hole will usually suffice if blood hematoma, associated fractures, and sidered reparable. tion must be as good as possible with is easily evacuated, but some prefer occult lacerations of the nailbed. These authors, however, suggest suturing the nailbed, and leaving the at- multiple holes. Blood usually spurts that if the SUH covers more than half tached nail in place is less traumatizing out under pressure, and then slowly of the nail surface or if there is a pha- in general. If the nail remains attached drains over the next few days. Gentle lanx fracture, fingernails should be at its margins, it’s best to let it be. pressure while the finger is still anes- Reader Feedback: routinely removed, the nailbed ex- Significant crush injuries, those thetized will initially squeeze out most Readers are invited plored, and lacerations sutured. In my that involve lacerations of the nail it- of the remaining blood (it rarely clots), to ask specific opinion, this aggressive stance is not self or the nail margin, and injuries and the patient can soak the finger in questions and offer substantiated by that report or subse- that avulse the nail are scenarios that cool salt water for a few days. It’s a personal experi- quent data, and seems to be overtreat- should be approached differently. In good idea to advise patients that the ences, comments, or observations ment for a minor injury that will heal cases where a nailbed laceration ex- original nail may fall off if there was on InFocus topics. Literature refer- nicely with a more conservative ap- tends to the skin or the nail is split, significant , but this is un- ences are appreciated. Pertinent re- proach. Once removed, it may take disrupted, or avulsed, it is generally usual or obvious at the time of injury. sponses will be published in a future four to five months (1 mm per week) agreed that the nail be completely re- Follow-up can be “as needed” in most issue. Please send comments to for a new nail to grow back. This is a moved, and the nailbed inspected and cases, with a caution about recurring [email protected]. Dr. Roberts requests long time to go without one’s finger- carefully repaired. hematoma and infection. A recheck at feedback on this month’s column, nail! And it’s not easy to repair a frag- I would order x-rays if specifically five to seven days for an injury with a especially personal experiences with ile nailbed. One must use a bloodless requested by the patient, if there were tuft fracture is prudent. successes, failures, and technique. field, very small absorbable sutures, a gross deformity, or if it were Some SUHs are produced from in- and orchestrate follow-up. important to predict accurately how juries that cause excessive flexion to InFocus October 2010 I EMN 23

the distal phalanx. A classic example is getting the fingertip slammed in a CME Participation Instructions door. One should always check for o earn CME credit, you must read the article in Emergency Medicine Acknowledgment will be sent to you within six to eight weeks of participation. avulsion of the extensor tendon (mal- TNews, and complete the evaluation questions and quiz, answering at Lippincott Continuing Medical Education Institute is accredited by let finger), and look for an avulsed nail least 80 percent of the questions correctly. Mail the completed quiz with your the Accreditation Council for Continuing Medical Education to provide check for $12 payable to Lippincott Continuing Medical Education Institute, medical education to physicians. Lippincott Continuing Medical Educa- base. In the excitement of draining the Inc., Two Commerce Square, 2001 Market St., Third Fl., Philadelphia, PA 19103. tion Institute designates this educational activity for a maximum of 1 hematoma, these injuries may be Only the first entry will be considered for credit, and must be received AMA PRA Category 1 Credit.™ Physicians should only claim credit missed, and produce a noticeable cos- by Lippincott Continuing Medical Education Institute by October 31, 2011. commensurate with the extent of their participation in the activities. metic deformity if treatment is not ini- tially correct. Blood should be seen October 2010 only under the nail itself. If there is Questions: blood in the paronychial area, the nail 1. Which of the following best identifies an SUH that can C. Use antibiotics if the patient is a child under 10. has been avulsed, allowing egress of be treated with simple nail trephination rather than nail D. Use antibiotics only if there are signs of infection. removal? nailbed blood to that area. This may A. Injury from a hammer blow to the thumb. 4. What best describes the proper technique to repair a not be obvious to the neophyte. If that B. Nail is intact, and nail margins are firm. nailbed laceration? is present, one can usually relocate the C. A linear not horizontal fingernail laceration is A. Leave the remaining nail attached and suture avulsed nail with a hemostat, eschew- present. directly though the nail. ing formal nail removal. D. There is blood under the cuticle. B. Approximate the disrupted nailbed with adhesive Roser et al randomized children with strips or tissue glue. a fingernail crush injury to simple 2. Which of the following is an unacceptable way to C. Meticulously suture the nailbed with absorbable trephination vs. nail removal or nailbed evacuate an SUH? sutures. repair. (J Hand Surg 1999;24[1]:116.) As A. Lift up the distal nail with a hemostat. D. Avoid sutures and allow for granulation to fill the with adult data, they found that nail re- B. a hole in the nail with a cautery. defect. moval and nailbed repair was not indi- C. Twirl an 18-gauge needle on the nail. D. Burn a hole with a heated paperclip. 5. Following a fingertip crush injury, what does blood cated or justified for children with SUH under the cuticle signify? with an intact nail or nail margin. Inter- 3. Which of the following best summarizes the use of A. The nail has been avulsed from the base by a estingly, these hand surgeons just could prophylactic antibiotics after SUH drainage? flexion force. not keep themselves from prescribing A. Use antibiotics if the hematoma is more than 48 B. There was direct blunt trauma to the proximal nail. routine antibiotics, an intervention hours old. C. The patient attempted prior drainage of an SUH. never proven to be warranted. If antibi- B. Use antibiotics if there is an underlying tuft fracture. D. There is an underlying coagulopathy. otics are opted, a first-generation Directions cephalosporin is a reasonable choice, Your successful completion of this activity includes evaluating it. Please indicate your responses below filling in the blanks or by darkening with MRSA not seemingly an issue. the circles with a pencil or pen. Finally, exemplifying a continued Please rate your confidence in your ability to achieve the following objectives, both before this activity and after it: 1 (minimally) to 5 (completely) Pre Post conundrum for the clinician, despite 12345 1 2345 substantial data and clinical experi- Formulate a plan to identify subungual hematomas that require simple ence, is a recent quite excellent emer- nail trephination vs. nail removal. gency medicine textbook on potential Select the correct method of providing nail trephination. errors in clinical practice. (Avoiding Predict the need for prophylactic antibiotics after hematoma evacuation. Common Errors in the Emergency Please indicate how well the activity met your expectations: 1 (minimally) to 5 (completely) 12345 Department. Philadelphia: Lippincott Was effective in meeting the educational objectives Content was useful and relevant to my practice Williams & Wilkins; 2010.) Despite a Please address the practical application of this activity below cogent review, the author promulgates How many of your patients may be affected by what you learned from this activity? ______a somewhat less-than-decisive stance Do you expect that the information you learned during this activity will help 12 345 on the two primary interventions: sim- you improve your skill or judgment within the next 6 months? ple trephination vs. nail removal. At (1-Definitely will not change, 5-Definitely will change) this juncture, one can unequivocally How will you apply what you learned from this activity? (Mark all that apply.) In diagnosing patients In making treatment decisions recommend simple trephination. In monitoring patients As a foundation to learn more In educating students and colleagues In educating patients and their caregivers Comments about this article? Write To confirm current practice As part of a quality/performance improvement project For maintaining board certification For maintaining licensure to EMN at [email protected]. Please complete these overall activity assessment questions. Yes No Did you perceive any bias for or against any commercial products or devices? Click and Connect! Access the links If yes, please explain: ______in this article by reading it on Compared with other educational activities in which you have participated 12345 www.EM-News.com. over the past year, how would you rate this activity? 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