to the editor: I read with keen interest the fine review by Drs. Wang and Johnson, entitled “Fingertip Injuries.”1 However, I disagree with the authors' proposal for the management of nail bed lacerations. In the presence of a subungual hematoma of at least 50 percent, they recommend removal of the nail with exploration for nail bed laceration and, if found, primary repair. This technique is believed to reduce the possibility of an unacceptable cosmetic or functional nail. I disagree with their statement that “attention to detail (in this regard) is critical in treating nail bed lacerations.”
This dogma regarding subungual hematomas and management of nail bed lacerations is a standard and widely disseminated notion that has been in orthopedic literature for years. However, there is no substantive proof for the technique's effectiveness or efficacy in preventing post-traumatic “ridged nail,” “split-nail” deformity, an irregular nail surface, or failure of the nail plate to adhere to the nail bed.
Although this issue is controversial and textbook recommendations are mixed,2,3 some evidenced-based data show that primary repair of nail bed lacerations is probably not necessary. If the nail plate is partially avulsed but is firmly attached to the nail matrix, exploring the nail bed is difficult and probably unwarranted.4 Even in the presence of significant subungual hematoma, with or without tuft fracture, the nail need not be routinely removed to search for nail bed laceration, as long as the nail is adherent and disruption of the surrounding tissue is minimal.5 A good cosmetic and functional outcome can be expected.
In a small, prospective study, Roser and Gellman6 compared outcomes of two groups of patients with fingertip injuries; one group was managed with surgery, and the other was managed without surgery. The first group consisted of 26 consecutive patients, aged eight months to 15 years, with crush injuries resulting in subungual hematomas involving more than 25 percent of the nail bed, with an intact nail and nail margin, who underwent operative repair under digital block. The second group included 26 consecutive patients, aged six months to 20 years, with 27 similar finger injuries managed nonoperatively, with either trephination (11 fingers) or observation without evacuation of the hematoma (16 fingers). Mean follow-up exceeded two years in both groups.
In the operative group in this study,6 75 percent of patients had subungual hematomas in excess of 75 percent and tuft fractures were present in 12 cases. In the nonoperative group, one third of the patients had subungual hematomas in excess of 75 percent and tuft fractures were present in 11 cases. Transient abnormalities were noted in three of the 26 nails in the operative group, and one additional nail exhibited insignificant cosmetic abnormality. One patient in the nonoperative group exhibited a transient nail depression. There were no infections. Notably, the average charge per patient was $1,263 in the operative group, compared with $283 per patient in the nonoperative group.
Based on the results in this series, it would certainly appear that routine nail plate removal and nail bed exploration is not required for patients sustaining subungual hematomas after a crush injury, as long as the nail and nail margins are intact.
editor's note: This letter was sent to the authors of “Fingertip injuries,” who declined to reply.