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Hunt TJ, Powlan FJ, Renfro KN, Polmear M, Macias RA, Dunn JC, Wells ME. Common Finger Injuries: Treatment Guidelines for Emergency and Primary Care Providers. Mil Med 2024; 189:988-994. [PMID: 36734106 DOI: 10.1093/milmed/usad022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/10/2022] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Finger and hand injuries are among the most common musculoskeletal conditions presenting to emergency departments and primary care providers. Many rural and community hospitals may not have immediate access to an orthopedic surgeon on-site. Furthermore, military treatment facilities, both within the continental United States and in austere deployment environments, face similar challenges. Therefore, knowing how to treat basic finger and hand injuries is paramount for patient care. MATERIALS AND METHODS The Armed Forces Health Surveillance Branch operates the Defense Medical Surveillance System, a database that serves as the central repository of medical surveillance data for the armed forces. The Defense Medical Surveillance System was queried for ICD-10 codes associated with finger injuries from 2015 to 2019 among active duty service members across the major branches of the military. RESULTS The most commonly reported finger injuries were open wounds to fingers without damage to nails, metacarpal fractures, phalanx fractures, and finger subluxation/dislocation. Emergency departments were the most commonly reported treatment facility type accounting for 35% of initial finger injuries, followed by 32.2% at orthopedic surgery clinics, 22.2% at family medicine clinics, and 10.8% at urgent care centers. CONCLUSIONS Finger injuries are common in the military setting and presenting directly to an orthopedic surgeon does not appear the norm. Fingertip injuries, fractures within the hand, and finger dislocations can often be managed without the need for a subspecialist. By following simple guidelines with attention to "red flags," primary care providers can manage most of these injuries with short-term follow-up with orthopedics.
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Affiliation(s)
- Tyler J Hunt
- Jack Hughston Memorial Hospital, Phenix City, AL 36867, USA
| | - Franklin J Powlan
- William Beaumont Army Medical Center, Fort Bliss, TX 79918, USA
- Texas Tech University Health Sciences Center of El Paso, El Paso, TX 79905, USA
| | - Kayleigh N Renfro
- William Beaumont Army Medical Center, Fort Bliss, TX 79918, USA
- Texas Tech University Health Sciences Center of El Paso, El Paso, TX 79905, USA
| | - Michael Polmear
- William Beaumont Army Medical Center, Fort Bliss, TX 79918, USA
- Texas Tech University Health Sciences Center of El Paso, El Paso, TX 79905, USA
| | - Reuben A Macias
- Blanchfield Army Community Hospital, Fort Campbell, KY 42223, USA
| | - John C Dunn
- William Beaumont Army Medical Center, Fort Bliss, TX 79918, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Matthew E Wells
- William Beaumont Army Medical Center, Fort Bliss, TX 79918, USA
- Texas Tech University Health Sciences Center of El Paso, El Paso, TX 79905, USA
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Braga Silva J. Fingernail injury in children. HAND SURGERY & REHABILITATION 2023:S2468-1229(23)00026-9. [PMID: 36682538 DOI: 10.1016/j.hansur.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 12/30/2022] [Accepted: 01/14/2023] [Indexed: 01/22/2023]
Abstract
Injuries to the nail complex are common in children. Most children who present with fingertip trauma have experienced a crush injury, usually from the hinge side of a door and often in the living room. This article reviews the literature on the management of fingertip crush injuries, fractures of the distal phalanx, nail bed injury and subungual hematoma to establish, where possible, best evidence.
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Affiliation(s)
- Jeffesron Braga Silva
- Service of Hand Surgery and Reconstructive Microsurgery, Pontifical Catholic University of Rio Grande do Sul Hospital São Lucas, Av. Ipiranga, 6690, Centro Clinico PUCRS, Suite 216, Porto Alegre, RS, 90610-000, Brazil; Hospital Moinhos de Vento, Av. Ramiro Barcelos 910, Porto Alegre, RS, 90035-000, Brazil.
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3
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Prabhu S, Singh J, Velmurugan P, Sundaramurthi S. Commentary on “Subungual hematoma: nail bed repair or trephination? A systematic review” by Silva JB, Becker AS, Leal BLM, Busnello CV, Kist EH & Koff ND. EUROPEAN JOURNAL OF PLASTIC SURGERY 2023. [DOI: 10.1007/s00238-022-02037-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Rao V, Akiki RK, Crozier JW, Bhatt RA, Schmidt ST, Kalliainen LK. Rethinking the Need for Nail Plate Removal: A Comparison of the Risks Between Standard Nail Bed Repair and Nonoperative Management. Ann Plast Surg 2022; 88:S209-S213. [PMID: 35513322 DOI: 10.1097/sap.0000000000003197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Nail bed injuries are commonly treated with nail plate removal and repair due to concern for future nail deformity. There is controversy whether this is necessary. We compared the outcomes for adult patients with simple nail bed lacerations who underwent either formal nail bed repair or nonoperative management. METHODS A retrospective cohort study was performed of adult patients with nail bed lacerations from 2012 to 2019. Nail bed lacerations were diagnosed in patients with fingertip injuries resulting in subungual hematoma greater than 50% or in any subungual hematoma in the setting of a distal phalanx fracture. All patients included had an intact nail plate. Patients were treated with nail bed laceration repair or nonoperatively without nail plate removal. The primary outcome was the development of a nail deformity. Secondary outcomes included infection, fracture nonunion, and patient-reported functional outcomes using the quick Disabilities of the Arm, Shoulder and Hand score. RESULTS Thirty-eight patients with nail bed lacerations were treated nonoperatively, and 40 patients were treated with nail bed repair. The average follow-up time was 4.5 weeks in the office. In addition, 1-year evaluation of patients was performed through telephone interview. The patients in the nonoperative group exhibited no statistically significant difference in the calculated risk for nail deformities compared with the nail bed repair group (13% vs 23%, relative risk = 0.58, P = 0.40, 95% confidence interval = 0.42-1.25). There were no significant differences in secondary outcomes or quick Disabilities of the Arm, Shoulder and Hand scores between groups. CONCLUSIONS The authors observed no meaningful difference in the rate of nail deformities in adult patients who underwent nail bed repair compared with those managed nonoperatively.
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Affiliation(s)
- Vinay Rao
- From the Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
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5
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Abstract
Appropriate management of the acute fingertip and nail bed injury is critical for optimizing patient outcomes. Mismanaged injuries can lead to chronic pain and deformity. Subungual hematomas may be treated with simple trephination for pain relief. Nail bed lacerations may be repaired using dissolvable suture or octyl-2-cyanoacrylate, and in most cases with no need to replace the nail plate or stent the fold. Amputations, partial or complete, can be treated with a wide variety of techniques, but many distal injuries can be left to heal by secondary intention with excellent results.
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Affiliation(s)
- Jessica B Hawken
- Orthopaedic Surgery, Medstar Orthopaedic Institute at Union Memorial Hospital, Baltimore, MD, USA
| | - Aviram M Giladi
- Hand Surgery and Plastic Surgery, The Curtis National Hand Center, MedStar Union Memorial Hospital, 3333 N. Calvert Street, JPB 2nd floor, Baltimore, MD 21218, USA.
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Abstract
Fingertip injuries in the military are common and often hinder the fighting force and support personnel. Injuries range from small subungual hematomas to proximal finger amputations. Treatment modalities are dictated by injury patterns, anatomic considerations, and the need to return to duty. Nail bed injuries should be repaired when possible and exposed bone or tendon is treated with appropriate soft tissue coverage. If soft tissue coverage is unobtainable, revision amputation should be performed with attention given to maintaining as much finger length as possible. Antibiotics may not be required, however they are often utilized in the deployed setting.
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Affiliation(s)
- Matthew E Wells
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, 5005 North Piedras Street, El Paso, TX 79902, USA; Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, 4801 Alberta Avenue, El Paso, TX 79905, USA.
| | - John P Scanaliato
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, 5005 North Piedras Street, El Paso, TX 79902, USA; Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, 4801 Alberta Avenue, El Paso, TX 79905, USA
| | - Nicholas A Kusnezov
- Department of Orthopaedic Surgery, Blanchfield Army Community Hospital, 650 Joel Drive, Fort Campbell, KY 42223, USA
| | - Leon J Nesti
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA; Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - John C Dunn
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, 5005 North Piedras Street, El Paso, TX 79902, USA; Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Abstract
Pediatric fingertip injuries are common and peak at 2 years of age. These injuries most frequently result from a crush mechanism and half sustain an associated fracture. The presence of a physis results in unique injury patterns and management considerations in the growing child. Due to a substantial healing potential in children, an initial conservative approach to management for many soft tissue and nail bed injuries is recommended. This article reviews the evidence and approach for treating pediatric fingertip injuries and amputations.
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Affiliation(s)
- Scott N Loewenstein
- Division of Plastic Surgery, Integrated Plastic Surgery Residency Program, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall, Suite 232, Indianapolis, IN 46202, USA
| | - Joshua M Adkinson
- Division of Plastic Surgery, Sidney and Lois S. Eskenazi Hospital, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall, Suite 232, Indianapolis, IN 46202, USA.
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8
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Bettlach CR, Pet M. Diagnosis and Management of Common Pediatric Fingertip Trauma. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2020.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Cruz SA, Stein SL. A review of sports‐related dermatologic conditions. TRANSLATIONAL SPORTS MEDICINE 2020. [DOI: 10.1002/tsm2.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Sarah L. Stein
- Section of Dermatology Departments of Medicine and Pediatrics University of Chicago Medicine Chicago IL USA
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10
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Management of Pediatric Distal Fingertip Injuries: A Systematic Literature Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2595. [PMID: 32095403 PMCID: PMC7015615 DOI: 10.1097/gox.0000000000002595] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/28/2019] [Indexed: 12/18/2022]
Abstract
Background: Nail bed and fingertip injuries are the commonest hand injuries in children and can lead to profound functional and cosmetic impairments if not appropriately managed. Fingertip injuries can present with subungual hematomas, simple or stellate lacerations, crush, or avulsion injuries, often with associated fractures or tip amputations. The fundamentals of managing nail bed injuries concern restoring the form and function of a painless fingertip. However, there are controversies surrounding the optimal management of each of these injuries, which has led to nonuniformity of clinical practice. Methods: The PubMed database was searched from March 2001 to March 2019, using a combination of MeSH terms and keywords. Studies evaluating children (<18 years of age) and the fingertip (defined as distal to the distal interphalangeal joint) were included following screening by the authors. Results and Conclusion: The evidence base for the diverse clinical management strategies currently employed for fingertip injuries in the pediatric population is limited. Further studies yielding level I data in this field are warranted.
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Abstract
The fingertip is mankind's tactile interface with the physical world, from reading braille, to using touchscreens, to wielding power tools. Its special tissue architecture demands astute evaluation and meticulous surgical or nonsurgical care after injury to return patients to their preinjury level of function. Attentive deliberation of physiologic, vocational, and psychosocial factors could improve the odds of achieving satisfactory results. In this article, we explore these aspects of fingertip injury to provoke readers to examine their practices and philosophies.
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Affiliation(s)
- Patricia Martin-Playa
- Department of Hand and Reconstructive Microsurgery, National University Hospital, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Anthony Foo
- Department of Hand and Reconstructive Microsurgery, National University Hospital, 1E Kent Ridge Road, Singapore 119228, Singapore.
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Carmès S. Description des lésions unguéales des doigts dans un service d’urgence. ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction: Nous rapportons une étude épidémiologique des lésions unguéales vues dans un centre de traumatologie de la main pendant une période de 18 mois. Les traumatismes unguéaux représentaient 8 % de tous les traumatismes des doigts.Méthodes: Nous avons pris en charge de façon continue 187 patients dont les dossiers ont été revus rétrospectivement.Matériel et résultats: Cent trente-huit hommes (74 %), avec un âge moyen de 38,5 ans, et 49 femmes (26 %), d’âge moyen de 46,1 ans. La main droite était atteinte 80 fois (43 %), la gauche 106 fois (57 %), et les données étaient manquantes dans un cas. Les patients étaient atteints sur leur main dominante dans 37%des cas. Le pouce était le doigt le plus souvent touché, 55 cas (29 %), puis le majeur (23 %), l’index (17 %), l’annulaire (15 %) et l’auriculaire (10 %). Dans 5 % des cas, il y avait plusieurs doigts touchés, et le majeur était alors toujours atteint. Un mécanisme d’écrasement était la cause la plus fréquente (44 %), avec un doigt coincé dans une porte dans 42 cas (23 %) ou écrasé par un objet (22 %). Venaient ensuite les plaies franches, 55 cas (30 %). L’exploration des lésions a retrouvé 47 lésions isolées de la tablette unguéale (25 %), 103 lésions du lit de l’ongle (55 %), 14 lésions de la matrice ± associées à une lésion du lit et 23 hématomes sous-unguéaux (12 %). Dans 134 cas (72 %), il existait une autre lésion associée à celle de l’ongle. Il s’agissait d’une lésion pulpaire dans 50 cas (27%), d’une fracture de la phalange distale dans 29 cas (16 %), d’une lésion associant à une fracture de la phalange distale une lésion de la pulpe dans 49 cas (26 %) et d’une autre lésion du doigt ou de la main dans 22 cas (12%). La lésion siégeait sur le même doigt dans 128 cas.Conclusion: Les lésions unguéales sont fréquentes. Le médecin urgentiste doit connaître ces lésions et ne pas les sous-estimer, car dans plus de trois quarts des cas elles nécessitent un geste technique qui relève le plus souvent de la compétence de l’urgentiste.
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13
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Fixation of the nail plate by tension band suture versus 2-octyl-cyanoacrylate gluing for traumatic nail bed injuries reduced without suture: A retrospective study of 27 cases. HAND SURGERY & REHABILITATION 2018; 37:180-185. [DOI: 10.1016/j.hansur.2017.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 11/29/2017] [Accepted: 12/05/2017] [Indexed: 11/24/2022]
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Giesen T, Adani R, Carmes S, Dumontier C, Elliot D, Calcagni M. IFSSH scientific committee on skin coverage: 2015 report. HAND SURGERY & REHABILITATION 2016; 35:307-319. [PMID: 27781975 DOI: 10.1016/j.hansur.2016.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 05/15/2016] [Accepted: 07/26/2016] [Indexed: 11/20/2022]
Abstract
Skin coverage in hand reconstruction is a challenging and vast chapter in hand surgery; covering every aspect of it in a report is simply not feasible. Therefore, this report focuses on a few specific topics. The coverage of anatomical regions like the fingertips is common ground for hand surgeons worldwide, but in the last 10 years, various refinements have been published in order to optimize the reconstruction of this organ. Nevertheless, in many emergency departments, the amputation of badly injured fingertips, including the thumb, remains the preferred treatment. The main focus of this report is to counter this tendency by providing alternatives to surgeons. Large defects in the fingers involving more than one segment, defects in the palm and in the dorsum of the hand are currently debated in international meetings. The use of skin substitutes vs. the use of extremely refined microsurgical procedures vs. classic island flaps has generated animated discussions, which are also influenced by cultural and socioeconomic factors around the world. This report offers the views of six surgeons from four different countries, in the hope of animating discussions and suggesting new approaches.
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Affiliation(s)
- T Giesen
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.
| | - R Adani
- Department of Hand Surgery, University Hospital of Modena, Modena, Italy
| | - S Carmes
- Department of Plastic Surgery and Hand Surgery, Nice University Hospital, Nice, France
| | - C Dumontier
- Department of Plastic Surgery and Hand Surgery, Nice University Hospital, Nice, France
| | - D Elliot
- Hand Surgery Department, St Andrew's Centre for Plastic Surgery and Burns, Chelmsford, Essex, UK
| | - M Calcagni
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
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Gungor F, Akyol KC, Eken C, Kesapli M, Beydilli I, Akcimen M. The value of point-of-care ultrasound for detecting nail bed injury in ED. Am J Emerg Med 2016; 34:1850-4. [DOI: 10.1016/j.ajem.2016.06.067] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 05/14/2016] [Accepted: 06/15/2016] [Indexed: 10/21/2022] Open
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Abstract
The nail is unique to primates as a specialized structure on the dorsum of the distal portion of each finger, thumb and toe. The nail allows for increased sensory perception on the volar pulp by compressing sensory organs against the unyielding nail. The nail is vital for increased prehension which is so unique in primate function. In addition it protects the fingertip and also serves as a temperature regulator.Fingertips are often our first contact with the environment, are one of the most common injuries presenting to a hand surgeon and may seriously impair the abilities of individuals if injured. The fingertip is the most sensitive part of the hand and has a large area of representation in the sensory cortex.The severity of injury to the nail bed is commonly underestimated because the nail conceals the true extent of injury. The consequences of mismanaged fingertip injuries is often manifest in the form of chronic nail and fingertip deformities, which are more difficult to treat than the original injury. It is therefore important for junior doctor to competently assess the patient, appreciate the potential disabilities and to arrange prompt referral to a hand unit. This article discusses the relevant anatomy, physiology and management of acute perionychial injuries.
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Affiliation(s)
- J Chakravarthy
- South Birmingham Trauma Unit, Selly Oak Hospital, Birmingham, UK,
| | - A Qureshi
- South Birmingham Trauma Unit, Selly Oak Hospital, Birmingham, UK
| | - M A Waldram
- South Birmingham Trauma Unit, Selly Oak Hospital, Birmingham, UK
| | - K Porter
- South Birmingham Trauma Unit, Selly Oak Hospital, Birmingham, UK
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Gil JA, DeFroda S, Reid D, Mansuripur PK. Closed traumatic finger tip injuries in patients with artificial nails: removal of UV gel and acrylic nails. Am J Emerg Med 2016; 34:335-7. [DOI: 10.1016/j.ajem.2015.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Indexed: 12/01/2022] Open
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Management of simple nail bed lacerations and subungual hematomas in the emergency department. Pediatr Emerg Care 2014; 30:742-5; quiz 746-8. [PMID: 25275357 DOI: 10.1097/pec.0000000000000241] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Fingertip crush injuries are common hand injuries in children and often are evaluated initially in an emergency department. Nail bed injuries can be classified into subungual hematomas, simple or stellate lacerations, crush injuries, and avulsions. Emergency department physicians with good knowledge of fingertip anatomy can appropriately manage these injuries so as to prevent long-term fingertip deformities and functional deficits. The management of simple nail bed lacerations and subungual hematomas has remained somewhat controversial with much debate surrounding the necessity of removing the nail plate for repair of a nail bed laceration versus trephination alone of a large subungual hematoma. This article will discuss the management and evaluation of simple nail bed injuries by emergency department physicians to prevent chronic nail and fingertip deformities.
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Abstract
BACKGROUND Fingertip entrapment injuries, which involve lacerations to the pulp and nail and often a fracture of the underlying bone, commonly occur in children, usually as the result of a crushing injury. Treatment is either conservative (wound cleaning and fingertip dressing)or surgical (repair of lacerations, reduction and stabilisation of fractures); however, no consensus currently exists regarding the most appropriate treatment modality. OBJECTIVES To assess the effects (benefits and harms) of surgical and conservative interventions for fingertip entrapment injuries in children. We aimed to compare: different methods of conservative treatment; surgical versus conservative treatment; different methods of surgical treatment; and different methods of management after initial conservative or surgical treatment. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE, EMBASE, the World Health Organization Clinical Trials Registry Platform and reference lists of articles up to 30 April 2013. We did not apply any restrictions based on language or publication status. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing interventions for treating fingertip entrapment injuries in children.The primary outcomes were fingertip function, nail growth, nail deformity and adverse events such as infection. DATA COLLECTION AND ANALYSIS Two authors independently screened studies for inclusion, assessed the risk of bias in each included trial and extracted data.We resolved disagreements through discussion. MAIN RESULTS We included two RCTs examining a total of 191 young children, 180 of whom were included in the analyses. The two trials tested different comparisons. Both trials were at high risk of bias, particularly from lack of blinding of participants and personnel, and of outcome assessment. The trials did not record fingertip function, nail growth or nail deformity. The quality of the evidence for the reported outcomes was judged to be 'low' using the GRADE approach (i.e. further research is very likely to have an important impact on our confidence in the estimate of the effect and is likely to change the estimate).One trial compared a seven-day course of antibiotics with no antibiotics after formal surgical repair of fingertip entrapment injuries.One child in each group had an infection at day seven (1/66 antibiotic group versus 1/69 no antibiotic group; RR 1.05, 95% CI 0.07 to 16.37). Both participants with infections had a more severe injury (partial fingertip amputation).The other trial compared two different dressings (silicone net and paraffin gauze) for use after either surgical or initial conservative management of fingertip entrapment injuries. It reported that two of 20 children in the silicone group versus one of 25 in the paraffin group had complications of wound infection (RR 2.50, 95% CI 0.24 to 25.63) and that one of 20 children in the silicone group versus two of 25 in the paraffin group had skin necrosis (RR 0.63, 95% CI 0.06 to 6.41). All complications healed with conservative treatment. The results for mean healing times and mean number of dressing changes were similar between groups but benefits of either silicone or paraffin dressings could not be excluded (silicone mean 4.1 weeks versus paraffin mean 4.0 weeks;MD 0.10 weeks, 95% CI-0.61 to 0.81); (silicone mean 4.3 dressing changes versus paraffin mean 4.2 dressing changes; MD 0.10, 95% CI -0.57 to 0.77). The trial found that a silicone dressing was less likely to adhere to the wound or cause distress for the child at the one-week dressing change. AUTHORS' CONCLUSIONS There is a lack of evidence from RCTs to inform all key treatment decisions for the management of fingertip entrapment injuries in children.Given that the quality of evidence is low from one trial, we do not have conclusive evidence that prophylactic use of antibiotics after surgical repair fails to reduce risk of infection. The two children who experienced infection had more severe wounds.Similarly, the low quality evidence from one trial has not enabled us to draw firm conclusions regarding the effect on healing time or complications (infection, skin necrosis) at four-week follow-up between a silicone net dressing and a paraffin gauze dressing when applied post-surgery or after simple wound irrigation; however, the silicone net dressing may be easier to remove in the first week.Further RCTs are required in this area, preferably comparing surgical with conservative methods of managing fingertip entrapment injuries. Outcome assessment should include fingertip function, nail growth and nail deformity for a minimum of three months posttreatment.
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Affiliation(s)
- Robert Capstick
- St Vincent's Hospital Melbourne41 Victoria PdeFitzroyVictoriaAustralia3065
| | - Henk Giele
- Oxford University HospitalsDepartment of Plastic, Reconstructive and Hand SurgeryOxfordOxfordshireUKOX3 9DU
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Mignemi ME, Unruh KP, Lee DH. Controversies in the treatment of nail bed injuries. J Hand Surg Am 2013; 38:1427-30. [PMID: 23751325 DOI: 10.1016/j.jhsa.2013.04.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2011] [Revised: 04/04/2013] [Accepted: 04/06/2013] [Indexed: 02/02/2023]
Affiliation(s)
- Megan E Mignemi
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA.
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21
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Loréa P. Primary care of nail traumas. ACTA ACUST UNITED AC 2013; 32:129-35. [DOI: 10.1016/j.main.2013.02.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Revised: 01/06/2013] [Accepted: 02/04/2013] [Indexed: 11/30/2022]
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Abstract
In the last 40 years, childhood hand and wrist injuries have become progressively more common as children have become heavier and more active in high impact sports. The majority of children with such injuries do well, but treatment is not always straightforward. Distal radius fractures, scaphoid fractures, metacarpal and phalangeal fractures, nailbed injuries, and amputations are among the pediatric hand and wrist injuries most often seen by orthopedists. These are all discussed, with a focus on the most recent literature and areas of evolving controversy.
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Affiliation(s)
- Ariel A. Williams
- Department of Orthopaedic Surgery, Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287 USA
| | - Heather V. Lochner
- Department of Orthopaedic Surgery, Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287 USA
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Dean B, Becker G, Little C. THE MANAGEMENT OF THE ACUTE TRAUMATIC SUBUNGUAL HAEMATOMA: A SYSTEMATIC REVIEW. ACTA ACUST UNITED AC 2012; 17:151-4. [DOI: 10.1142/s021881041230001x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Accepted: 06/18/2011] [Indexed: 11/18/2022]
Abstract
There is no consensus regarding the optimal mode of managing the acute traumatic subungual haematoma in the hand. In this context the medical literature was searched systematically and the results analysed. The final dataset consisted of four articles. The complication rates of all forms of treatment were low. The outcome in terms of nail cosmesis was generally good, although the method of outcome measurement was variable in nature. There was no difference in cosmetic outcome when comparing nail bed repair with simple decompression. In conclusion the outcome in terms of nail cosmesis does not appear to be affected by the mode of treatment. The acutely painful subungual haematoma should be decompressed, whether this be done by trephining or nail removal. Future research includes the potential for a randomised controlled trial to compare nail bed repair with trephination.
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Affiliation(s)
- Benjamin Dean
- Department of Orthopaedics, High Wycombe General Hospital, UK
| | - Giles Becker
- Department of Hand Surgery, Chelsea and Westminster Hospital, London, UK
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Tos P, Titolo P, Chirila NL, Catalano F, Artiaco S. Surgical treatment of acute fingernail injuries. J Orthop Traumatol 2011; 13:57-62. [PMID: 21984203 PMCID: PMC3349021 DOI: 10.1007/s10195-011-0161-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Accepted: 09/19/2011] [Indexed: 11/04/2022] Open
Abstract
The fingernail has an important role in hand function, facilitating the pinch and increasing the sensitivity of the fingertip. Therefore, immediate and proper strategy in treating fingernail injuries is essential to avoid aesthetic and functional impairment. Nail-bed and fingertip injuries are considered in this review, including subungual hematoma, wounds, simple lacerations of the nail bed and/or matrix, stellate lacerations, avulsion of the nail bed, ungual matrix defect, nail-bed injuries associated with fractures of the distal phalanx, and associated fingertip injuries. All these injuries require careful initial evaluation and adequate treatment, which is often performed under magnification. Delayed and secondary procedures of fingernail sequelae are possible, but final results are often unpredictable.
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Affiliation(s)
- P Tos
- Department of Orthopedics and Traumatology, UOD Reconstructive Microsurgery, CTO-M. Adelaide, Via Zuretti 29, 10126, Turin, Italy.
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Affiliation(s)
- Alexanderw Shaw
- Department of Plastic Surgery, Wexham Park Hospital, Slough SL2 4HL
| | - John Findlay
- Department of Trauma and Orthopaedic Surgery, Royal Berkshire Hospital, Reading
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Affiliation(s)
- Adam J Singer
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY 11794, USA.
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Abstract
Fingertip injuries are a potential cause of significant morbidity within the workplace and the community. Although they account for a low proportion of ED presentations, importantly they can frequently be managed entirely by emergency staff. A literature review was undertaken to identify the epidemiology, the assessment process and the management options for fingertip injuries as relevant to emergency medicine.
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Affiliation(s)
- Waruna de Alwis
- Emergency Department, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.
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29
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How Low Should You Go. Dermatol Surg 2006. [DOI: 10.1097/00042728-200606000-00013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vinel H. [What are the surgical indications in podiatry?]. Ann Dermatol Venereol 2006; 132:775-81. [PMID: 16419508 DOI: 10.1016/s0151-9638(05)79444-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- H Vinel
- Chirurgien orthopédiste, Centre Hospitalier du pays d'Aix, Avenue des Tamaris, 13616 Aix en Provence 1.
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31
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Cordoro KM, Ganz JE. Training Room Management of Medical Conditions: Sports Dermatology. Clin Sports Med 2005; 24:565-98, viii-ix. [PMID: 16004920 DOI: 10.1016/j.csm.2005.03.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Athletes' skin is subject to a distinct array of physical and environmental stressors. Trauma, the elements, and pathogenic organisms constantly challenge the skin's integrity. This article intends to arm the clinician with a fundamental knowledge of infections, mechanical injuries, and environmental insults common to the skin of athletes. Photographs corresponding to the described entities are included as figures. Because rapid return to play is the ultimate goal after injury or illness, there is a section dedicated to play restrictions as set forth by the National Collegiate Athletic Association. Although the evaluation and management of cutaneous disease is a challenging endeavor, a consistent and systematic approach to this most accessible organ can result in early diagnosis, appropriate treatment, and ultimate performance.
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Affiliation(s)
- Kelly M Cordoro
- Department of Dermatology, University of Virginia Health Sciences Center, Box 800718, Charlottesville, VA 22908, USA.
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Salazard B, Launay F, Desouches C, Samson P, Jouve JL, Magalon G. Les traumatismes des phalanges distales chez l’enfant. ACTA ACUST UNITED AC 2004; 90:621-7. [PMID: 15625512 DOI: 10.1016/s0035-1040(04)70722-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE OF THE STUDY Fingertip crush injuries are frequent in young children. Rigorous care is required to avoid esthetic and functional sequelae, but treatment is often difficult. We report our experience focusing on simple therapeutic principles useful for everyday practice in the emergency room. MATERIAL AND METHODS We reviewed retrospectively 91 fingertip injuries in 81 children followed for at least one year. Mean age of the children was 4.5 years. Crush injuries predominated (82%) and mainly involved the middle finger. We recorded the initial lesions, therapeutic interventions, and early complications. At last follow-up, we recorded sensitivity, aspect of the pulp and nail, and the subjective assessment of the parents. RESULTS There were four infectious including three periungual and subungual felons and two necrotic complications. One child developed a bone infection that required surgery and antibiotics. At last follow-up, seven patients (8%) had sensorial disorders, six (7%) an inesthetic pulp and 23 (25%) dystrophic nails (minor=19, major=4). The parents felt the result was very good for 80% of the children,. Pulp sensitivity disorders were more frequent when the nail bed was injured. Nail dystrophy was more frequent after initial pulp amputation. DISCUSSION The nail plays an important role in finger function, increasing tactile sensitivity and facilitating prehension. Fingertip injuries can be considered benign but require careful initial evaluation and rigorous management. If a sub-ungual hematoma covers more than half of an intact nail, puncture with a cold lancet appears to be indicated to avoid infection and reduce pain. Perforation with a heated instrument (paper clip) is easy to perform but the hematoma may reform rapidly. In the event of fracture, perforation should always be performed. Detached nails should be removed to examine the nail bed which must be sutured carefully if injured. Pulp lesions should also be sutured.
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Affiliation(s)
- B Salazard
- Service de Chirurgie Plastique, Hôpital Timone-Enfants, 264, rue Saint-Pierre, 13385 Marseille 05
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33
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Extra-Fine Insulin Syringe Needle. Dermatol Surg 2003. [DOI: 10.1097/00042728-200311000-00014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Kaya TI, Tursen U, Baz K, Ikizoglu G. Extra-Fine Insulin Syringe Needle: An Excellent Instrument for the Evacuation of Subungual Hematoma. Dermatol Surg 2003; 29:1141-3. [PMID: 14641342 DOI: 10.1046/j.1524-4725.2003.29359.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The most commonly used treatment method for subungual hematoma is nail trephining, which has some disadvantages. OBJECTIVE To introduce a very simple and well-tolerated treatment technique for this common problem. METHODS We used an extra-fine, 29-gauge insulin syringe for evacuation. We inserted the needle very close to the nail plate to minimize pain. We drained the blood from the hyponychium under the nail plate using this extra-fine needle. RESULTS The technique described herein is very fast and simple, and the patients tolerate it well. It is particularly successful for the treatment of smaller subungual hematomas of the second, third, and fourth toenails, in which the trephining is harder. CONCLUSION For these reasons, we suggest this technique as a practical alternative to the traditional nail trephining methods.
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Affiliation(s)
- Tamer Irfan Kaya
- Department of Dermatology, Mersin University, School of Medicine, 33079 Zeytinlibahce, Mersin, Turkey.
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Abstract
Nails enhance pulp sensibility, increase pulp stability and are necessary for fine prehension. A finger without a nail will compromise a musician's career if the finger involved is necessary to play a note (strings, keyboards) or hold a position (winds). Salvage of the nail is then a very important part of any surgical procedure in musicians with distal finger trauma. Surgical techniques will depend on the level and type of nail injury. Replantation is by far the best technique in distal finger amputation but, when not feasible, reposition-flap repair may be used. In isolated nail lesions, sutures, split-thickness nail bed graft, or nail matrix flaps are used according to the level and severity of the lesion.
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Abstract
Although many consider the fingertip injury a very mundane and simple problem, the mismanagement of this injury can often lead to a chronic esthetic and possibly painful deformity. As noted in this article, the appropriate understanding of the involved structures of a fingertip injury as well as the meticulous management of these injuries can generally lead to a very esthetic and functional fingertip. As previously noted by Elvin Zook, there is probably nowhere that Meskimen's Law, "There is never time to do it right but there is always time to do it over," is more true.
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Affiliation(s)
- Richard E Brown
- Springfield Surgical Associates, Springfield Clinic, Southern Illinois University School of Medicine, 501 North First Street, P.O. Box 19248, Springfield, IL 62794-8248, USA.
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Goodman GJ, Nicolopoulos J, Howard A. Diseases of the generative nail apparatus. Part II: nail bed. Australas J Dermatol 2002; 43:157-68; quiz 169-70. [PMID: 12121391 DOI: 10.1046/j.1440-0960.2002.00588.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Nail bed insults may affect the resultant nail product in a number of ways. If focal in nature, the severity and duration of the insult will determine the appearance of the nail product. Widespread insults may alter the size, shape or colour of the nail plate. Nail bed insults tend to present with more immediacy than nail matrical insults, as there is no need to wait until the nail grows out until the sign is obvious. We are less interested in the history of the event, than we are with the clinical sign being presented to us. Should treatment be required for focal nail bed insults, treatment is likely to be local and curative. Widespread nail bed insults may be associated with systemic diseases and if a result of local problems these may be difficult to treat.
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Affiliation(s)
- Greg J Goodman
- Skin and Cancer Foundation of Victoria, Carlton, Victoria, Australia.
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38
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Rizzo M, Levin LS. Hand Surgery. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
The fingernail and toenail are unique to primates. The anatomy and physiology of the nail must be understood for nail care to be effective. The most common cause of deformity of the nail bed is trauma, which requires careful suturing and postoperative care if the desired results are to be achieved. Congenital anomalies, tumors, and infection can also cause nail deformities and can frequently be corrected or improved surgically.
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Affiliation(s)
- E G Zook
- Institute for Plastic and Reconstructive Surgery, Southern Illinois University School of Medicine, Springfield 62794-9653, USA
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Abstract
The majority of skin trauma incidents cause minor injury that can be treated effectively in the outpatient setting. A new approach to the closure of skin lacerations using tissue adhesive is presented and the current management of abrasions, blisters, burns, skin tears, and subungual hematomas are reviewed. An overview of wound dressings is provided to assist in obtaining the optimal wound-healing environment.
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Affiliation(s)
- A S Pearson
- Saginaw Cooperative Hospitals/Michigan State University Emergency Medicine Residency Program, Saginaw, Michigan 48602, USA
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Helms A, Brodell RT. Surgical pearl: prompt treatment of subungual hematoma by decompression. J Am Acad Dermatol 2000; 42:508-9. [PMID: 10688726 DOI: 10.1016/s0190-9622(00)90228-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- A Helms
- Washington and Jefferson College, Washington, USA
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Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg Am 1999; 24:1166-70. [PMID: 10584937 DOI: 10.1053/jhsu.1999.1166] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Fifty-three fingers in 52 children were divided into 2 groups, operative and nonoperative, after fingernail crush injury. Criteria for inclusion into the study were an intact nail and nail margin with subungual hematoma and no previous nail abnormality. The length of the follow-up period averaged longer than 2 years for each group. Twenty-six fingers in 26 children were treated by nail removal, exploration, and repair of nail bed lacerations (operative group). Twenty-seven fingers in 26 children were treated by evacuation of hematoma by nail trephination without nail removal in 11 fingers and by observation in the other 16 fingers (nonoperative group). In the operative group, transient abnormalities (nail depression or hypertrophy), which resolved by 4 months, occurred in 3 patients. In the group treated by simple decompression, there were no complications except for 1 transient nail depression at 3 months. The average cost to the operative group was $1,263 compared with $283 to the trephination group. Although formal nail bed reconstruction has been advocated for hematomas larger than 25%, we found no notable difference in outcome between the 2 groups regardless of hematoma size, presence of fracture, injury mechanism, or age. Charges, however, were 4 times greater for the operative group. Based on the results of this study, we do not feel that nail removal and nail bed exploration is indicated or justified for children with subungual hematoma and an intact nail and nail margin.
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Affiliation(s)
- S E Roser
- Department of Orthopaedic Surgery, University of Arkansas for Medical Science, Little Rock 72205, USA
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43
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Harrison BP, Hilliard MW. Emergency department evaluation and treatment of hand injuries. Emerg Med Clin North Am 1999; 17:793-822, v. [PMID: 10584103 DOI: 10.1016/s0733-8627(05)70098-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This article focuses on disorders of the hand most commonly presented to the practitioner in an emergency setting. An initial review of functional anatomy is followed by discussions of the clinical findings and treatment of fractures, tendon injuries, infections, nailbed injuries, high-pressure injection injuries, and nerve injuries. The information presented in this article provides a basis for proper evaluation, diagnosis, and treatment of hand injuries.
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Affiliation(s)
- B P Harrison
- Emergency Medicine Residency Program, Darnall Army Community Hospital, Fort Hood, Texas, USA
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Kanegaye JT. A rational approach to the outpatient management of lacerations in pediatric patients. CURRENT PROBLEMS IN PEDIATRICS 1998; 28:205-34. [PMID: 9740986 DOI: 10.1016/s0045-9380(98)80048-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Lacerations are a frequent reason for pediatric health care visits. Many are referred to EDs or to surgical specialists but may be treated by the pediatrician who has the time and interest in maintaining wound care skills. Although skin closure is often viewed as the primary event in wound care, local anesthesia and wound toilet are equally important aspects in which expertise is often undervalued. On occasion, patient anxiety and resistance complicates wound care, and a variety of sedative techniques facilitates completion of procedures that otherwise would require general anesthesia. Adherence to basic principles and the occasional use of innovations in wound care enable the clinician to bring about optimal outcomes.
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Affiliation(s)
- J T Kanegaye
- Division of Emergency Medicine, Children's Hospital and Health Center, San Diego, California, USA
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Abstract
OBJECTIVES To determine the outcome of treating subungual haematomas by simple trephining, in terms of nail appearance and function, and to identify factors associated with a poor outcome. METHODS Patients with subungual haematomas attending an accident and emergency department over a 12 month period were identified; 5-13 months after injury a telephone and postal survey of patient's assessment of their own outcome was made using a proforma. Outcome was graded according to published criteria. RESULTS 123 patients with 127 subungual haematomas were identified and 74% were followed up; 85% achieved an "excellent" or "very good" result, with 67% reporting no residual abnormalities. A "poor" outcome occurred in only 2% owing to nail splitting. No correlation was found between adverse outcome and haematoma size, presence of fracture, or infection. CONCLUSIONS Treatment of subungual haematomas by simple trephining gives an acceptable result in the majority of patients and those with a poor outcome cannot be predicted at presentation. The findings suggest that only simple trephining for symptomatic relief is required for subungual haematomas and that aggressive surgical treatment is unnecessary.
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Affiliation(s)
- S Meek
- Accident and Emergency Department, Frenchay Hospital, Bristol
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