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/

Dressing a Central Line Properly

Welcome to one-of-maybe-more series of pearls based off my pet peeves.

Tim’s Pet Peeves Pearls

Magnificent.

Anyways as many of our residents know, central lines placed in the emergency department are frequently changed shortly after transfer to the ICU out of concern that lines were not placed under sterile technique. Not an ideal situation, as repeat catheter placement results in additional risk and discomfort to the patient. 

A year ago I asked one of our (now graduated) ICU fellows about this practice, and he mentioned that when he sees an improperly dressed central line (e.g. dressing partially falling off, not completely sealed), he feels obligated to change the line as it seems less clear whether or not that line was placed under sterile technique and has remained sterile.

While lines may still be exchanged regardless once patients have left our care, we should learn how to best dress and maintain sterility on our central lines. Let’s prevent those catheter-related bloodstream infections!

The lesson today was taught to me a couple years ago by our fabulous resus nurse Minh Duong. 

How to Dress a Central Line

Huzzah, you nailed your central line. Fantastic! Sutured down and everything. Now while you still have your sterile gown and mask on, you open your central line dressing kit. Inside you see a dressing, chlorhexidine swabs, barrier film, and extra PPE.

1. Use your chlorhexidine swabs and clean from inside to outside along the length of the catheter. Clean the line itself! 

2. Flip the swab and go back and forth over the surrounding skin. 

3. Repeat with the remaining swabs (there are multiple swabs in the kit)

4. Allow the site to dry. No need to fan or blow on the site.

5. Take your Sureprep Protective Wipe and draw a rectangle around the catheter site. The dressing will not stick well to the chlorhexidine, but will stick well to the SurePrep barrier film. This is important to make sure the dressing seals properly.

6. Place the dressing over the catheter so that the chlorhexidine-impregnated gel layer overlies the entrance of the catheter into the skin. Important for preventing those catheter infections!

7. Remove the sides of the dressing and press firmly along the sides to ensure that the dressing lies flat along the skin. For IJs, this often requires pulling a small amount of tension along the skin to have the dressing lay flush against the skin along the curves of the neck.

8. Take the next largest piece of the dressing (from the wings of the initial piece) and place it UNDER the catheter but OVER the dressing to create a closed loop around the catheter. Press firmly so the dressing lies flush against the skin.

9. Take the final thin piece of dressing from the remaining wing and apply it overtop the area where the catheter exits the dressing. Label the final piece with the current date.

If applied properly you now have a sealed dressing around a CVC. Do this properly, take a little extra time and your nurses and ICU will love you. Congrats!

Sources

https://www.youtube.com/watch?v=BVZq4WgfzQ4

https://www.youtube.com/watch?v=aMxahVmCR2E

https://www.youtube.com/watch?v=DGL8CzKTgVo

POTD: Felon

POTD: Felon

• Subcutaneous pyogenic infection of the pulp space compartment of the distal finger

• Can often be confused with paronychia or herpetic whitlow (fingertip pain but should not cause taut erythema) which can sometimes present with volar erythema

• High risk to progress to osteomyelitis, Flexor Tenosynovitis!

Clinical Features:

• Erythematous, edematous, tense distal pulp space with significant pain and tenderness

• May see necrotic appearing tissue distally due to increased pressure in space 

Work Up:

• Usually diagnosed clinically

• XR: No foreign body, soft tissue swelling pulp of thumb

• US: Use the water bath technique to see a potential fluid collection

• Digital Nerve Block

• I & D is the cornerstone of management: 

• Apply a latex glove finger tourniquet

• If the felon is on patient’s index, middle or ring finger, make the incision of the ulnar aspect

• If the felon is on patient’s thumb or pinky, make the incision of the radial aspect

• Using your #11 blade start your incision 5mm distal to flexor DIP crease and end 5mm proximal to nail plate border. Digital arteries and nerves arborize near DIT. Avoid those!

• Blunt dissect and break any loculations until the abscess is decompressed

• Avoid the "fishmouth" incision. Potentially can cause an unstable finger pad, neuroma or loss of sensation

• Antibiotics: Cover for Staph (MRSA) and strep

Disposition: 

• Home with follow up in the hand clinic or ED in 1-2 days. 

Check out this video to see it done:  

• www.emrap.org/episode/felonincision/felonincision 

Stay well,

TR Adam

Hello, World!