Nail bed trauma reconstruction and artificial nail replacement - a case report.

Nail bed reconstruction is crucial after fingertip trauma, impacting both function and aesthetics. In this article, the authors describe a case of partial distal phalanx amputation of the index finger with laceration of the nail bed's remaining part. A traumatically elevated skin-fat flap covered the exposed bone on the fingertip, preserving finger length and sensitivity on the radial side. A full-thickness skin graft from the forearm closed a secondary defect on the finger pulp. Nail bed suturing prevented scarring and nail deformity, and a temporary artificial plastic nail replacement maintained the nail bed's shape. Temporary artificial nail replacements protect the regenerating fingertip bed, promote healing, and prevent nail deformities. Proper adaptation of lacerated nail bed edges, supported by either the patient's own nail or a temporary artificial nail, is crucial for optimal fingertip restoration, including proper nail shape.

[Effectiveness of finger reconstruction using nail flap anastomosing nerve branch of the first toe nail bed].

Objective: To investigate the effectiveness of finger reconstruction using nail flap anastomosing the nerve branch of the first toe nail bed. Methods: Between January 2016 and December 2022, 18 patients (18 fingers) with thumb or finger nail bed defects were admitted. There were 12 males and 6 females, with an average age of 32 years (range, 19-42 years). Four cases were finger tip tissue damage caused by machine compression, and 4 cases were distal tissue necrosis after finger replantation. There were 9 cases of thumb injury, 3 cases of index finger injury, 5 cases of middle finger injury, and 1 case of ring finger injury. There were 11 cases of distal nail damage and 7 cases of distal nail root (including nail root) damage. The time from injury to admission was 1-5 hours, with an average of 2 hours. After debridement and anti-infection treatment for 5-7 days, the wounds in size of 1 cm×1 cm to 4 cm×3 cm were reconstructed by using nail flaps anastomosing the nerve branches of the first toe nail bed. The size of the nail flaps ranged from 1.5 cm×1.5 cm to 4.5 cm×3.5 cm. The donor sites were repaired with the flaps in 16 cases and skin graft in 2 cases. Results: All nail flaps, flaps, and skin grafts survived after operation and the wounds healed by first intention. All patients were followed up 6-12 months (mean, 10 months). The nails of 18 cases were all grown, in which 16 cases had smooth nails with satisfactory appearances, 1 case had uneven nails, and 1 case had obvious scar hyperplasia around the suture opening. At 6 months after operation, the two-point discrimination of the skin flap was 4-8 mm (mean, 6 mm). Meanwhile, the skin grafts and flaps at the donor sites regained protective sensation, good abrasion resistance, and had no negative effect upon walking and wearing shoes. Conclusion: The application of a nail flap that anastomoses the nerve branch of the first toe nail bed for finger reconstruction has minimal damage and can achieve good nail bed repair results.

The reconstruction of fingertip injury by mini hallux toenail flap pedicled with the hallux transverse artery and toe pulp vein transplantation technique based on the equivalent design theory.

INTRODUCTION: How to reconstruct the damaged fingertip is a clinical problem. Our team propose the theory of equivalent design and use the mini toenail flap pedicled with the hallux transverse artery and toe pulp vein transplantation technique to reconstruct Allen's type II fingertip injury. Thus, we perform the retrospective study to evaluate the effects of this technique on fingertip injury. MATERIALS AND METHODS: A retrospective analysis was performed on 56 patients admitted to our hospital from January 2015 to January 2020 who used equivalently designed miniature hallux toenail flaps for the plastic repair of fingertip damage. We recorded the size of the miniature hallux toenail flap, operation time, intraoperative blood loss, and complications and calculated the survival rate of the transplanted miniature hallux toenail flap. During routine follow-up after surgery, we recorded nail growth time and observed finger appearance. At the last time of follow-up, we recorded Semmes-Weinstein evaluating tactile sensation and Two-point discrimination testing (TPD). The efficacy was evaluated by Zook score evaluation. RESULTS: The size of the mini hallux toenail flap was 0.71 cm × 1.22 cm to 0.88 cm × 1.71 cm. The operation time was (3.54 ± 0.58) hours, the intraoperative blood loss was (20.66 ± 4.87) ml, and the survival rate of mini hallux toenail flaps was 100%. The postoperative follow-up time was (30.82 ± 11.21) months, and the total nail growth time was (9.68 ± 2.11) months. The average tactile sensation evaluated by the Semmes-Weinstein test was (0.32 ± 0.14) g, and the average TPD was (7.33 ± 1.02) mm. According to Zook score, the curative effect of fifty-six cases were all excellent or good with 100% excellent and good rate, and all patients had beautiful appearances and good function of damaged fingertips. CONCLUSIONS: Based on the equivalent design theory, the mini hallux toenail flap pedicled with the hallux transverse artery and toe pulp vein transplantation technique is an effective method to reconstruct Allen's type II fingertip injury with a beautiful appearance and good function. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Cost-effectiveness of replacing versus discarding the nail in children with nail bed injury.

Every year in the UK, around 10 000 children need to have operations to mend injuries to the bed of their fingernails. Currently, most children have their fingernail placed back on the injured nail bed after the operation. The NINJA trial found that children were slightly less likely to have an infection if the nail was thrown away rather than being put back, but the difference between groups was small and could have be due to chance. This study looked at whether replacing the nail is cost-effective compared with throwing it away. Using data from the NINJA trial, we compared costs, healthcare use, and quality of life and assessed the cost-effectiveness of replacing the nail. It was found that throwing the nail away after surgery would save the National Health Service (NHS) £75 (€85) per operation compared with placing the nail back on the nail bed. Changing clinical practice could save the NHS in England £720 000 (€819 000) per year.

Effectiveness of nail bed repair in children with or without replacing the fingernail: NINJA multicentre randomized clinical trial.

BACKGROUND: Surgery for nail bed injuries in children is common. One of the key surgical decisions is whether to replace the nail plate following nail bed repair. The aim of this RCT was to assess the clinical effectiveness and cost-effectiveness of nail bed repair with fingernail replacement/substitution compared with repair without fingernail replacement. METHODS: A two-arm 1 : 1 parallel-group open multicentre superiority RCT was performed across 20 secondary-care hospitals in the UK. The co-primary outcomes were surgical-site infection at around 7 days after surgery and cosmetic appearance summary score at a minimum of 4 months. RESULTS: Some 451 children presenting with a suspected nail bed injury were recruited between July 2018 and July 2019; 224 were allocated to the nail-discarded arm, and 227 to the nail-replaced arm. There was no difference in the number of surgical-site infections at around 7 days between the two interventions or in cosmetic appearance. The mean total healthcare cost over the 4 months after surgery was €84 (95 per cent c.i. 34 to 140) lower for the nail-discarded arm than the nail-replaced arm (P < 0.001). CONCLUSION: After nail bed repair, discarding the fingernail was associated with similar rates of infection and cosmesis ratings as replacement of the finger nail, but was cost saving. Registration number: ISRCTN44551796 (http://www.controlled-trials.com).

Does the Nail Bed Regenerate?

BACKGROUND: The regenerative potential of the nail bed after trauma remains controversial. METHODS: We performed a retrospective review of 51 patients who underwent nail bed reconstruction with 2 techniques (direct flow island flap or a Tranquilli-Leali "Atasoy" flap) due to trauma involving the nail bed complex. These 2 flaps were used to support the loss of distal substance and to allow the regeneration of the nail bed. Outcomes were analyzed for at least 18 months. There were 34 men (66.7%), and the average age was 16.1 years. Most patients (56.9%) had crush injuries. The little (16) and index (14) fingers were the most affected. Twenty-seven were children (range: 4-11) with an average age of 7.4 ± 1.9 years. The middle finger was the most affected (29.2%). RESULTS: The outcomes were good to excellent in 41 operated patients (80.4%). Hook nail was absent in 84.3% of the patients. Most patients (98%) did not develop necrosis. Children had an excellent/good outcome rate of 85.2%, while in adults, the rate was 75% of cases (P = .485). CONCLUSION: The direct flow island flap is superior in terms of outcome, regardless of age, sex, affected finger, dominant hand, type of trauma, and injury zone. In cases where there was a correct reconstruction of the hyponychium, there was regeneration of the nail bed.

Effectiveness of finger reconstruction using nail flap anastomosing nerve branch of the first toe nail bed / 中国修复重建外科杂志

OBJECTIVE@#To investigate the effectiveness of finger reconstruction using nail flap anastomosing the nerve branch of the first toe nail bed.@*METHODS@#Between January 2016 and December 2022, 18 patients (18 fingers) with thumb or finger nail bed defects were admitted. There were 12 males and 6 females, with an average age of 32 years (range, 19-42 years). Four cases were finger tip tissue damage caused by machine compression, and 4 cases were distal tissue necrosis after finger replantation. There were 9 cases of thumb injury, 3 cases of index finger injury, 5 cases of middle finger injury, and 1 case of ring finger injury. There were 11 cases of distal nail damage and 7 cases of distal nail root (including nail root) damage. The time from injury to admission was 1-5 hours, with an average of 2 hours. After debridement and anti-infection treatment for 5-7 days, the wounds in size of 1 cm×1 cm to 4 cm×3 cm were reconstructed by using nail flaps anastomosing the nerve branches of the first toe nail bed. The size of the nail flaps ranged from 1.5 cm×1.5 cm to 4.5 cm×3.5 cm. The donor sites were repaired with the flaps in 16 cases and skin graft in 2 cases.@*RESULTS@#All nail flaps, flaps, and skin grafts survived after operation and the wounds healed by first intention. All patients were followed up 6-12 months (mean, 10 months). The nails of 18 cases were all grown, in which 16 cases had smooth nails with satisfactory appearances, 1 case had uneven nails, and 1 case had obvious scar hyperplasia around the suture opening. At 6 months after operation, the two-point discrimination of the skin flap was 4-8 mm (mean, 6 mm). Meanwhile, the skin grafts and flaps at the donor sites regained protective sensation, good abrasion resistance, and had no negative effect upon walking and wearing shoes.@*CONCLUSION@#The application of a nail flap that anastomoses the nerve branch of the first toe nail bed for finger reconstruction has minimal damage and can achieve good nail bed repair results.

Salter-Harris Type III Fracture of the Distal Phalanx: A Rare Juxtaphyseal Variant.

Juxtaphyseal fractures of the distal phalanges of upper extremity digits are most commonly of the Salter-Harris II variety and occur most commonly in the thumb. The diagnosis of this injury is essential as it may present as an open fracture with a nailbed injury ("Seymour fracture"). However, an intra-articular, epiphyseal fracture may also occur and mimic a mallet deformity or Seymour fracture. Prompt diagnosis is essential to rule out an open fracture and obtain anatomical alignment and stability to attempt to reduce complications such as physeal arrest. Here, we present a patient with a displaced Salter-Harris type III fracture of his thumb distal phalanx and review his management and early-term outcome. We present this case to bring attention to this rare and unique injury, review the available literature, and discuss management and outcomes.

Up in Flames: The Safety of Electrocautery Trephination of Subungual Hematomas with Acrylic Nails.

INTRODUCTION: Subungual hematomas are fingertip injuries, generally secondary to blunt trauma, that cause pain due to an accumulation of blood under the fingernail. It is generally considered standard of practice to relieve this accumulation by means of trephination with a hollow tip needle, a heated paper clip, or electrocautery. It has been assumed that due to the flammable properties of acrylic, trephination via electrocautery has the potential to ignite acrylic nails and cause burns and other potentially serious injury, making electrocautery contraindicated in patients with acrylic nails. Our thorough literature review failed to support or refute this assumption; so in the interest of ensuring that this practice is evidence-based, we sought to explore this topic. METHODS: In this study we used electrocautery trephination on acrylic nail products attached to simulated digits and recorded the presence and frequency of ignition events. We hypothesized that ignition would occur with sufficient frequency to support continuing the practice of avoiding electrocautery trephination in subungual hematomas with overlying acrylic nails. RESULTS: In our study, we exposed 200 acrylic nails to trephination with electrocautery, and 83 nails ignited (41.5%). CONCLUSION: While other variables exist, these findings do support the current practice pattern of avoiding trephination with electrocautery in those patients with acrylic nails overlying subungual hematomas.

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.

Nail matrix scars that result in nail dystrophy resemble cutaneous scars: A new nail trauma model.

BACKGROUND: Few studies have described how the injury affects the nail soft tissue under the nail plate. Nail matrix scar is poorly known. OBJECTIVE: To establish a stable rat nail loss model in a simple way, and to discuss the comparability of this model. METHODS: A sterile cotton swab dipped in a 10% NaOH solution was used to burn the entire nail matrix and bed plane region, and the specimens were examined on day 3, 7, 14, and 28. RESULTS: After avulsion of the nail plate, the eponychia and matrix stuck together without any tissue destruction. On day 28, all claws of the experimental group were observed to be permanently damaged, except for one claw malformed regeneration. All impaired nail regeneration had deficiency or functional loss of NMSCs and shared similar characteristics with the cutaneous scars. CONCLUSIONS: The scar formation of nail matrix was a fundamental reason to nail deficiency of rat or human, providing a research basis for further mechanism or treatment study of nail defect diseases.

Fingertip injury epidemiology: an Indian perspective.

Fingertip injuries result in significant morbidity. It is associated with pain, loss of work and recreational hours, financial burden, and distortion of body image. Although it is a common injury, the epidemiology of fingertip injury is a subject with scanty literature. This study is aimed at providing epidemiology of fingertip injury in India. Epidemiological data were collected and analysed through a retrospective review of all fingertip injuries over a period of four years treated in our department. In the paediatric population, among the 241 injuries in 221children, most occurred at home (98%). Most incidents were in children under five years of age (74%). The most commonly involved digit is the middle finger (29%) and door crush was the commonest reason (80%). Incomplete fingertip amputation with nail bed injury was seen in 80% of cases. In adults, there were 351 injuries in 290 patients, most of which occurred by jamming of the finger at a two-wheeler chain (22.5%). The second most common cause is cut by machine and associated with heavy machinery (17.6%). Complete amputation at the nailbed level was seen in 50% of the cases. Both children and adults need to be educated regarding the causation and effects of fingertip injuries. Damage to fingers can be prevented and reduced by observing safety measures both inside the home and at the workplace.

A new surgical strategy for reconstruction of claw nail deformity.

Claw nail deformity is common in patients with fingertip injury. The optimal reconstruction remains unclear. We devised a unique strategy for reconstruction of claw nail deformity. We divided the approach into three parts: soft tissue reconstruction, bone graft and nail bed graft. In the soft-tissue reconstruction, a reverse digital arterial finger flap for the finger or an extended palmar flap advancement with V-Y plasty for the thumb was selected. A part of the distal phalanx of the second toe including periosteum was harvested as a bone graft. A nail bed graft from the big toe was performed. We reconstructed in 11 cases of claw nail deformity using our strategy. All cases achieved significant improvement with no recurrence of the claw nail deformity. Moreover, there was no donor site morbidity.

Onychoscopy in a Colombian population with a diagnosis of toenail onychomycosis: an evaluation study for this diagnostic test.

BACKGROUND: Onychoscopy is a technique that uses a dermatoscope for the evaluation of specific features of different skin conditions that are not visible to the naked eye. There are few studies establishing parameters for the diagnosis of onychomycosis based on onychoscopy. Determining the sensitivity and specificity of a potentially new diagnostic test for onychomycosis requires an evaluation study of this new diagnostic test, as there are limited studies reporting onychoscopy results. AIM: To determine the sensitivity, specificity, positive predictive value and negative predictive value of onychoscopy findings in a Colombian population with onychomycosis. METHODS: We assessed outpatients with a diagnosis of toenail onychomycosis confirmed by potassium hydroxide preparation or fungal culture. Onychoscopy was performed using a dermatoscope, and digital images collected using a smartphone. RESULTS: The onychoscopy findings were: longitudinal striae, distal spiked pattern, distal irregular termination, linear edge and ruins aspect, while some patients were confirmed as having traumatic onycholysis. A statistically significant association was found between the clinical symptoms of onychomycosis and both the clinical feature of dyschromia and the onychoscopy feature of longitudinal striae. CONCLUSION: We suggest that this technique is an alternative method that should be used in patients with onychopathies because it has the potential to differentiate onychomycosis from traumatic onycholysis and another nail involvement.

Salvaging a Totally Avulsed Nail Bed Using Free Grafting and Postoperative Ice Cooling: A Case Report.

Most nail bed injuries occur along with other fingertip injuries; however, isolated total avulsion injuries of the nail bed are uncommon. To obtain optimal results, reconstructive methods should be selected judiciously depending on the type of injury, the patient's needs for their economic status and postoperative aesthetics, and postoperative morbidities. Replantation with an avulsed nail bed, if feasible, can be a reasonable treatment option to avoid the morbidities of other donor sites. This report presents a rare case of a 26-year-old man who experienced an isolated total avulsion injury of the nail bed with exposure of the phalangeal bone while using machinery, which was treated successfully with free grafting and postoperative ice cooling.

Non-operative treatment versus suture refixation of the nail plate in paediatric fingernail avulsion injuries.

The study compared a non-operative treatment, consisting of ointment dressing only, with the standard surgical nail plate refixation for simple fingernail avulsion injuries in children. A non-inferiority hypothesis was tested in a single-centre, prospective cohort study. The quality of the new nail was the primary outcome and was assessed with the Nail Appearance Score. The secondary outcome was patient and parental satisfaction, which was assessed with the Patients' and Parental Nail Satisfaction Score. Fifty-one patients were enrolled; 39 (76%) chose the non-operative treatment and 12 (24%) the standard operative therapy. Comparison of the two groups confirmed the non-inferiority hypothesis with a risk difference for the new nail of -0.02 with a 95% confidence interval of (-0.05, 0.01). The outcome was excellent in all fingers with no significant differences regarding either the primary or secondary outcome. In view of associated risks and costs for surgery, we recommend ointment dressings for such injuries.Level of evidence: II.

Suture Stabilization of Open Physeal Fractures of the Great Toe Distal Phalanx (Seymour Fracture).

BACKGROUND: Open physeal fractures of the distal phalanx of the hallux are analogous to Seymour fractures of the hand. When missed, these injuries can result in long-term sequelae including infection, pain, nail deformity, and physeal arrest. Nevertheless, there is a paucity in the literature regarding optimal surgical treatment for these challenging injuries. We present a novel technique and case series for suture-only stabilization of Seymour fractures of the great toe. METHODS: Billing records were used to identify all children aged 18 years or younger who underwent operative treatment open distal phalanx fracture of the hallux with an associated nail bed injury. Electronic medical records and plain imaging were reviewed to identify mechanism of injury, surgical technique, results, complications, and follow-up. RESULTS: Five boys with a mean age of 10.3 years (range, 5 to 13 y) met inclusion criteria. Forty percent (2/5) of injuries were missed by the initial treating providers. Only 2 patients presented to our institution primarily; 60% (3/5) patients were transferred from other facilities. The mechanism of injury was variable but generally involved "stubbing" the toe. The mean time from injury to surgical treatment was 2.6 days (range, 0 to 6 d). Median follow-up was 2 months (range, 1 to 96 mo). No patient complications (including infection) or reoperations were reported. On follow-up imaging, no physeal bars were evident on patients treated with suture-only technique. CONCLUSIONS: Seymour fracture of the hallux are uncommon, and there is frequently a delay in both presentation and diagnosis. Providers should have increased suspicion for these injuries when a physeal fracture of the great toe is associated with bleeding or nail bed injury. Currently, no consensus exists for treatment of these injuries. Suture-only stabilization represents a simple, reliable alternative to pin fixation. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Pediatric Seymour Fractures of the Toe.

BACKGROUND: Seymour fractures of the toe are physeal fractures with often occult concomitant nail bed injuries and thus are open fractures. They are uncommon injuries that without proper treatment can result in osteomyelitis. The literature has sparse information regarding the clinical outcomes for these injuries. METHODS: A single-center retrospective review included juxta-epiphyseal fractures or Salter-Harris I/II fracture of the toe with documented concomitant nail bed injury or laceration. Clinical and radiographic data were recorded for consecutive fractures. The primary outcome was the incidence of osteomyelitis. Secondary outcomes included premature physeal arrest, development of nail dystrophy, and functionality of the toe. RESULTS: Between 2006 and 2019, 19 patients were treated for this injury by the pediatric orthopaedic division. Complications included osteomyelitis (n=6), physeal arrest (n=4), and nail dystrophy (n=1). Days from injury to definitive treatment were significantly greater in patients who developed osteomyelitis compared with those who did not (P<0.01). Patients were significantly more likely to develop osteomyelitis if they did not receive acute definitive treatment (<48 h) (P<0.001; likelihood ratio, 17.9). CONCLUSIONS: Prompt definitive treatment of Seymour fractures of the toe was associated with a lower incidence of osteomyelitis. Greater awareness for these seemingly innocuous injuries is needed to provide an early treatment that may reduce the rate of osteomyelitis. LEVEL OF EVIDENCE: Level IV-case series.