Pediatric emergency medicine trisk 3339 3339
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Copious irrigation is required with all wounds, with extra attention paid to
open fractures. If wound debridement is felt to be required, the emergency
physician should consult with a hand specialist to avoid debriding vital structures
such as the nail bed, which could result in permanent effects on subsequent nail
growth.
Management
Severe nail bed injuries require nail removal if nail avulsion was not part of the
initial injury. Wounds should be cleaned and the often friable tissue should be
repaired with 5-0 or 6-0 absorbable suture, typically chromic gut. Newer studies
in both adults and children have found equivalent outcomes using tissue adhesive.
Common practice is to keep the nail fold open for the new nail to form; available
placeholders include the salvaged nail, sterile aluminum (from suture packaging),
or a nonadhesive dressing. The placeholder should be secured to the fingertip,
commonly with sutures, both proximally and distally to ensure that it does not get
removed prematurely. Care must be taken to avoid further damage to the germinal
matrix and injury site when affixing the nail. Absorbable sutures are preferred; if
nonabsorbable sutures are used, they should be removed early in the course at
follow-up with a hand specialist, to prevent wound tracks during nail
development. Tissue adhesive has been used as an alternative to sutures to secure
the placeholder. While some recent literature suggests that stenting the nail fold
may not be necessary, supporting data are limited at this time and therefore
current recommendations are to aim to maintain a patent nail fold.
