w w w . r b o . o r g . b r
Original
Article
Trauma
to
the
nail
complex
夽
Jefferson
Braga
Silva
a,b,∗,
Samanta
Gerhardt
baHandSurgeryandReconstructiveMicrosurgeryService,HospitalSãoLucas,PontifíciaUniversidadeCatólicadoRioGrandedoSul
(PUC-RS),PortoAlegre,RS,Brazil
bFaculdadedeMedicinadaPontifíciaUniversidadeCatólicadoRioGrandedoSul,PortoAlegre,RS,Brazil
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Articlehistory:
Received10March2013 Accepted10October2013 Availableonline12March2014
Keywords:
Nail
Fingerinjuries Nailbed
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Objective:toanalyzetheresultsfromsurgicalinterventiontotreattraumaofthenail com-plex.
Methods:weretrospectivelyreviewedaseriesof94consecutivepatientswithtraumaofthe nailcomplexwhoweretreatedbetween2000and2009.In42patients,nailbedsuturingwas performed.In27patients,nailbedsuturingwasperformedsubsequenttoosteosynthesisof thedistalphalanx.In15,immediategraftingwasperformed,andin10,late-stagegrafting ofthenailbed.Thegrowth,sizeandshapeofthenailwereevaluatedincomparisonwith thecontralateralfinger.Theresultswereobtainedbysummingscoresandclassifyingthem asgood,fairorpoor.
Results:theresultswereconsideredtobegoodparticularlyinthepatientswhounderwent nailbedsuturingornailbedsuturingwithosteosynthesisofthedistalphalanx.Patients whounderwentimmediateorlate-stagenailgraftinghadpoorresults.
Conclusion: traumaofthenailcomplexwithoutlossofsubstancepresentedbetterresults thandiddeferredtreatmentforreconstructionofthenailcomplex.
©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.
Trauma
do
complexo
ungueal
Palavras-chave:
Unha
Traumatismodosdedos Leitoungueal
r
e
s
u
m
o
Objetivo:analisarosresultadosdaintervenc¸ãocirúrgicadotraumadocomplexoungueal.
Métodos:revisamos94pacientesconsecutivoscomtraumadocomplexounguealentre2000 e2009.Em42pacientesfoifeitaasuturanoleitoungueal.Em27,asuturadoleitofoiposterior àosteossíntesedafalangedistal.Em15,foifeitoenxertoimediatoeem10,enxertotardio doleitoungueal.Foramavaliadosocrescimento,otamanhoeaformadaunhacomparados aodedocontralateral.Osresultadosforamobtidoscomaadic¸ãodeescoreseaclassificac¸ão delescomobom,regulareruim.
Resultados: foramjulgadoscomobonsospacientesquesesubmeteramprincipalmentea suturasdoleitounguealesuturadoleitoeosteossíntesedafalangedistal.Pacientes sub-metidosaenxertoimediatoeenxertoposteriordaunhativeramresultadosruins.
夽
Pleasecitethisarticleas:SilvaJB.Traumadocomplexoungueal.RevBrasOrtop.2014;49:111–115.
∗ Correspondingauthor.
E-mail:[email protected](J.B.Silva).
emergencyservices.2,3
Fingertiptraumawithor withoutexposureofthe distal phalanxcanbetreatedindifferentways,usinggraftsandlocal flaps.Inthenailmatrixandinnailbedtrauma,different tech-niquescanalsobeusedtoachieveestheticandfunctionalnail growthoverthelongterm.3
Forthisobjective,avarietyoftechniqueshavebeenused: nailperforationwithremovalofthesubungualhematoma, suturingofthenailbed,osteosynthesisofthedistalphalanx ofthenailandevennailbedgrafts.
Material
and
methods
Wereviewed109patients withtrauma ofthe nailcomplex seenbetweenJanuary2000andDecember2009.Themeanage was19years(range:16–48).Theinclusioncriteriawerethat thesepatientsneededtohavenailbedinjurieswithorwithout associatedfracturesofthedistalphalanx,withaminimum follow-upof18months.Ofthesepatients,15wereexcluded becausewedidnotreachthepostoperativelengthoffollow-up proposedforthestudy,thusleaving94patients.Thesurgery wasallperformedbythesameteam,underlocoregional anes-thesia,orundergeneralanesthesiaincasesthatrequirednail bedgraftingfromthehallux.In42patients,weperformed sim-plesuturingofthenailbed(SS)(Figs.1–5);in27,suturingofthe nailbedfollowedbyosteosynthesisofthedistalphalanx(SO); in15,immediategraftingofthenailbed(IG);andin10,later graftingofthenailbed(LG),i.e.morethanfivedaysafterwards.
Fig.1–Crushingofthethumb,withsubungualhematoma.
Fig.2–Crushingofthethumb:volarview.
Fig.3–Nailbedinjury.
Fig.5–Finalresult.
Thenailbedsuturingwasdoneusingpolyglactin6.0thread. Whenavailable,thetraumatizednailswerealways recondi-tionedandwere placedundertheproximalfoldofthenail andeponychium.Thispolicyenabledbetteralignmentofthe nailbedsutureandgreatercomfortforpatientsatthetimeof applyingdressings.Whentheoriginalnailwasnotavailable,a plateofsyntheticmaterialwasimprovisedfromasmallpiece offlexiblesiliconethatwastakenfromthesalinesolutionbags thatareavailableinanysurgicalfacility.Provisional immobi-lizationwasusedfortwoweeks.Incasesoffracturingofthe distalphalanx,twocrossedKirschnerwiresandavolar Zim-mersplintwereuseduntilradiologicalconsolidationhadbeen achieved(meanofsixweeks).Thedonorzoneforthenailbed graftwasalwaysthenailbedofthehallux(Figs.6–9).
Weassessedwhetherage,sex,injurymechanism,typeof treatmentusedandtimewhenthetreatmentwasperformed hadanyinfluence,andalsoevaluatedtheestheticand func-tionalresultsrelatingtothenailcomplex.
Results
Sexandagedidnothaveanyinfluenceontheresultsobtained. There was a direct relationship between the injury mech-anism, type oftreatment used, time when treatment was performedandtheestheticandfunctionalresultsobtainedin
Fig.6– Traumaofthenailcomplex.
Fig.7–Repairofthenailbed.
Fig.8–Siliconelamina.
Fig.9–Finalresult.
thisstudy.Fortheresultstobebetterassessed,wedeveloped atableofscoresthatincludedthreefactors(Table1).
We assessed nail growth (0=without growth; 1=partial growth with restraints; and 2=normal growth), nail size (0≤50%;1=between50and75%;and 2≥75%ofthesizeof
ticalplane;and2=withoutdeformity),incomparisonwiththe oppositeside.Theresultswereobtainedthroughadditionand classificationofthescoresasgood(5–6),fair(3–4)andpoor(<3). Theresultswerejudgedtobegoodinthefollowingpatients: SS(37/42);SO(23/27);IG(2/15);andLG(1/10).Poorresultswere foundinIGpatients(8/15)andLGpatients(6/10)(Table2).
Discussion
Traumaofthenailcomplex isthe maincause of consulta-tionsinhandsurgeryemergencies.Traumawithorwithout exposureofthedistalphalanxandwithorwithout fractur-ingcanbetreatedindifferentways,throughusinggraftsor regionalflaps.Themainfunctionsofthenailsaretoprovide stabilityforfingergripsthroughcounterpressureandesthetic definitionfortheextremitiesofthefingers.
Nailcomplextraumaisoftenmanifestedindifferentways: subungualhematoma,lacerations,crushingandavulsionof thenailbed.Hematomasoccurduetomicrovasculartrauma inthenailbed,whichcompressesthebloodcoagulumbelow the nail. Understanding the delicate relationship between the nail and the dorsum of the fingertip and its vascular irrigationmaycontributetowardunderstandingtheneedfor goodrestorationofthenailbed,inordertoensurerecovery of the local anatomy. Microvascular studies have demon-stratedthedifferencebetweentheeponychium,nailbedand irrigationofthenailmatrix.4
Itisknownthattheentirenailbedisinvolvedin germina-tionandmigrationofthecornifiedcellsofthenail.Forthis reason,itisnecessarynotonlytopreservethegerminative matrixbutalsotorestoreallofitsstructures,therebymaking
nailsurface).Painreliefandthesimplicityoftheprocedure arethemainadvantageswhenthistreatmentisinstitutedin emergencysituations.
Weprioritizethreefactorsinevaluatingandclassifyingthe resultsaftertreatmentwithdifferentmethods:nailgrowth, measuredaccordingtothelengthofthenail;nailsize,in com-parisonwiththecontralateralfinger;andnailshape,through measuringthedeformityintheverticalplane.
Different studies have shown similarities in the results fromnailbedsuturing,incomparisonwithtreatmentsusing cyanoacrylate tissueadhesives.2,6,7 Along the same line of
investigation,comparisonsbetweentissueadhesivesandnail bed suturing have been made, without showing any sig-nificant differences in the results.8 For avulsion or severe
crushingofthenailbedandfingertip,thelossoftissue mate-rial needsto be replaced bymeans of nail bed grafts and regionalflaps.Manyflapsforreconstructionofthefingertip havebeendescribed.Thetypeandmechanismofthe finger-tiptraumaandtheinvolvementofthenailbeddeterminethe choiceofreconstruction. Nailbed grafts mayoftenbe per-formedwithinacuteanddelayedcontexts.Thesesituations arelimitedmainlybythetimeatwhichthepatientcomesfor consultationandthecaregivenwithintheacutescenario.
Incasesofavulsionorcrushing ofthe nailbedand fin-gertip,thelossoftissuematerialneedstobereplacedusing grafts and/or localflaps. There isa considerablevarietyof therapeuticoptionsfordistalfingerreconstructions. Same-fingerneurovascularflapscanbehighlighted.Nailbedgrafts canbeperformedwithinanacuteanddelayedcontext. Dif-ferent donorsitescanbeusedforthispurpose;the matrix and the nail bedofan amputated segmentfrom a toe are mostcommonlyusedasfullorpartial-thicknessgrafts.Itis
Table2–Results.Nailgrowthaftertreatmentofdifferentpatternsoftraumaofthenailcomplex. Lacerationofthenail
bed+hematoma
Lacerationofthenailbed+fracturingof thedistalphalanx
Lossoftissuesubstance/avulsion–severe crushing
Treatment SSa SOb IGc LGd
Good 37 23 2 3
Fair 5 4 5 1
Poor 0 0 8 6
Total 42 27 15 10
a Simplesuturingofthenailbed–SS.
b Suturingofthenailbedfollowedbyosteosynthesisofthedistalphalanx–SO. c Immediategraftingofthenail–IG.
importanttotakeintoaccountthepossibilityofscarringor possibledeformityofthenailatthedonorlocation.9,10
Conclusion
Theresultsfromthisstudyclearlyshowedthattraumadueto crushingwithlossoftissuematerialanddeferredtreatment ofthenailcomplex(>5days)presentedoutcomesthatwere inferiortothoseofcasesinwhichthetreatmentwasdoneas anemergencyandinwhichtherewasnosignificantlossfrom thenailcomplex.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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