POTD: Trauma Tuesday - Nailed it!

For my final Trauma Tuesday POTD, I’m going to cover the topic of open nailbed lacerations.

What really matters most on initial inspection is any disruption to the proximal nail fold and lunula, which would suggest damage to the germinal matrix. Your fingernail grows from the germinal matrix, so if there is any disruption to that, the answer is easy. Stop and consult hand surgery. This patient is going to need a germinal matrix graft which is beyond our scope as ED docs.

If any of these other findings are also present, hand surgery consultation would also be indicated:

-              Infected wounds

-              Disruption of digital tendons

-              Displaced or unstable finger fractures that may require ORIF

-              Complicated digit dislocations

-              Fingertip amputations that include loss of nail and/or bone and fingertip pulp

However, if you note that the proximal nail fold and lunula look largely intact and all you have is a laceration to the nailbed + an avulsed nail, you can take care of that!

In an open nailbed laceration, you need to remove the nail and suture the nailbed. Controversy exists regarding replacing the nail. Nail splinting has been traditionally recommended to maintain the proximal nail fold during healing, prevent scarring and nail deformity, reduce infection, and decrease pain during dressing changes.

The most recent NINJA RCT in 2023 did not show difference in cosmetic appearance or infection rate at 7-10 days whether or not the nail was splinted in children, though these findings did not reach statistical significance.

Steps

Laceration repair:

1. Perform a digital block and have patient soak fingertip in saline while block is taking effect.

2. Placing a digital tourniquet may help minimize blood in field during repair.

3. Remove fingernail by gently separating the underlying adherent nail bed from nail.

   • Insert scissors or hemostat in closed position between nail and nail bed at distal tip and advance slowly in proximal direction.

   • Open and spread instrument while maintaining tips against undersurface of nail to avoid further injury to nail bed

4. Gently irrigate nail bed with 100-200 cc of NS.

5. Repair nailbed using 6-0 absorbables (chromic gut or vicryl rapid)

   • Direct needle from distal to proximal when passing needle to avoid tearing nailbed tissue.

   • Can alternatively use dermabond. In meta-analyses, using tissue adhesives was considered as effective as sutures for nailbed lac repair.

To splint with original nail:

1. Gently clean nail in dilute solution of povidone iodine and NS.

2. Place 3-4mm diameter hole in center of nail using sterile needle, scalpel, or cautery to allow drainage of any blood.

3. Replace nail beneath the proximal fold and secure in place with 2-3 drops of tissue adhesive. Can also suture nail in place (video below shows how you can do this).

4. If original nail can’t be used, place a nonadherent splint with single thickness of sterile gauze, silicon sheeting, or sterile foil from suture packet and hold in place with absorbable 4-0 sutures through lateral skin folds or skin glue.

Also repair any other lacerations outside of the nailbed (finger pad or folds) with 4-0 or 5-0 absorbable sutures.

Remove the tourniquet, apply a protective dressing, and you’re done!

Prior to discharge:

Update Tdap

Leave dressing in place until follow up visit with hand surgery within 7 days.

Most up to date guidelines suggest AGAINST routinely administering empiric abx, but consider using it in animal/human bites, excessive wound contamination, or patients with vascular insufficiency or immunocompromised states. Several randomized trials have not shown any benefit to giving abx. 

Make sure the patient understands that the nail is there to maintain patency of the proximal fold and that it will fall off within 1-3 weeks. A new nail will grow completely in 3-12 months. Despite our best efforts, scarring may still impact nail regrowth.

TL;DR: Check out below for an EMRAP video on nailbed laceration repair that basically sums this all up.

https://www.emrap.org/episode/nailbed/nailbed

References

https://www.uptodate.com/contents/evaluation-and-management-of-fingertip-injuries

https://www.emdocs.net/evidence-based-approach-to-nailbed-injuries-ed-presentations-evaluation-and-management/

https://www.aliem.com/trick-trade-nail-bed-repair-tissue-adhesive-glue/

https://first10em.com/the-ninja-trial-do-you-replace-the-fingernail-after-nail-bed-repair/

POTD: How to read a CT of the c-spine

Hello everyone,

I’m going to review the ABCS of reading a c-spine CT in today’s Trauma Tuesday. It’s something we order a lot of in the ED, so it’s good to have a standardized approach, just like we do with CXRs.

A = alignment: Best evaluated in the mid-sagittal view, evaluate the 4 smooth curves formed by the anterior and posterior surfaces of the vertebral bodies and the bases/tips of the spinous processes.

B = bones: In addition to looking at the vertebral bodies and spinous processes for breaks or loss of height, pay special attention to the arches/ring of C1 and the dens of C2.

C = cartilage: Assess the spaces between each vertebra, looking for widening, narrowing, or asymmetry.

S = soft tissue: Look at the pre-vertebral soft tissues in the mid-sagittal slice. Note that the soft tissue contour should parallel the vertebral bodies and is narrow from C1-C4.

There’s a couple of “spaces” to be aware of which I think is much easier to see rather than explain in written form so in the references below is a link to a short, helpful video that explains all this while showing you it at the same time!

References

https://www.youtube.com/watch?v=XY9xpI3EHec

https://coreem.net/core/the-abcs-of-reading-c-spine-cts/

POTD: Eye'm Scared!

Does anyone else get freaked out by stuff involving the eye? Well, not after this POTD you won’t.

Today I’m going to cover eyelid lacerations, probably one of the trickier ones we can encounter in the ED. First off, you must rule out corneal injury and globe rupture. Once that has been done, you can move on to considering the repair.

Repairing eyelid lacs are within the realm of the ED physician, but only under certain conditions. If any of the following findings are present, then you should involve an ophthalmologist for definitive repair.

·      Involvement of the lid margin >1mm

·      Within 6-8mm of the medial canthus (suggesting lacrimal duct/sac involvement) – can lead to poor drainage, excessive tearing and recurrent conjunctivitis or stye!

·      Through and through lacerations (involves the tarsal plate)

·      Ptosis (suggesting levator palpebrae muscle involvement)

To repair, considering using a supraorbital block or infraorbital block depending on location. Topical LET or EMLA may be considered if applied carefully to prevent leakage into eye. Then use very fine material such as 6-0 or even 7-0 sutures. These should be removed in 5-7 days and pt should follow up with an ophthalmologist ideally.

Some cool tricks tricks of the trade:

1)  To check for lacrimal duct involvement: can instill fluorescein carefully over cornea only and place a wood’s lamp over laceration. If fluorescence in wound, that means you have lacrimal duct involvement

2)  Use Tegaderm and cut a window into it using fine scissors to approximate the size/shape of wound you want to repair. Place over area of interest and can use tissue adhesive to glue together laceration; any glue run-off will get on Tegaderm instead!

3)  Use tetracaine and then place a Morgan Lens under the lids to act as an eye shield to prevent iatrogenic globe rupture while suturing.

References

https://lacerationrepair.com/techniques/anatomic-regions/lacerations-around-the-eye/

https://wikem.org/wiki/Eyelid_laceration