Authors: Rob Hirst, Liz Farah, Andy Neill, Dave McCreary, Chris Connolly, Becky Maxwell / Codes: HC8, RP4, SLO5, TC5, TP10 / Published: 07/06/2024
Question
Do you put the nailbed bcak in when fixing a nail bed repair in kiddos
Title - Effectiveness of nail bed repair in children with or without replacing the fingernail: NINJA multicentre randomized clinical trial
Authors
Jain et al BJS
Background
I will confess immediately I haven’t looked after a nail bed injury in about 4 years now but back in the day when i was a proper emergency doctor I used to love a good nail bed repair. I remember lots of debate about what to do with the nail, do you suture it back in, do you even need to suture the laceration underneath it. - it's clear from the authors intro that current surgical practice in kids is to remove the nail, fix the nail bed then replace the nail. but is that needed?
Methods
This is a multi centre randomised trial in kids of a surgical intervention. That deserves some kudos and s much of a state as the NHS is in right now it's clear that the NHS can pull this off. - these are all hand surgery units, so it's clear that this isn't an ED based paper as everywhere ive worked the paeds nail beds tend to get shipped out to plastics rather than being dealt with in house. - randomised to either nail bed replacement (or if the nail was ruined they could use the foil packet of the suture cut to size) or simply dressing the repaired nail bed - follow up was at clinic in person and mailed questionaires as 4 and 12 months. - outcomes were infection and nail appearance. Which are by no means the same - nail appearance used a scale that rejoices in the name of the zook score.
Results
- 450 pts
- SSI were uncommon (7) with most in the group were the nail was replaced. This may well be random noise.
- no difference in cosmetic appearance
Thoughts
I think this is a great and well done trial for what is a really common procedure. It's hard to see how it directly affects us in ED but bear with us while i lay on an anecdote - a few years ago i put my dominant index finger in a reciprocating saw doing some DIY and gave myself a nice nail bed lac and almost completely avulsed nail. To avoid the shame of going to my own ED and crying like a baby during a ring blcok i stood at the sink and replaced the nail back under the cuticle with great swearing and covered it up with a sticky plaster. The finger wasnt' much use for about 3 weeks but the nail fell off and another grew back and its all fine now. - so we now no that shocing the nail back in to cover the wound is probably not a good idea but the real question now is, do we repair the nail bed at all? Indeed the authors posit this very question. "This study has addressed this issue and laid the foundation for asking a further question: Should the nail bed be repaired or not? Nail bed injuries encompass a wide spectrum of injury severities. For instance, a sizeable proportion might be amenable to being cleaned in the emergency department and dressed with adhesive strips. " - Now i don't want to imply that my undorubtedly heroic management of my finger injury heralded in a new era of finger injury managment but i do hear some people are saying that... - genuinely if we can proved that neither repauiring the nail bed or replacing the nail is beneficial then it will make life easier for everyone.
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