EXTERNAL FIXATION OF INJURED NAIL BED WITH THE INRO SURGICAL NAIL SPLINT

Transcription

1 EXTERNAL FIXATION OF INJURED NAIL BED WITH THE INRO SURGICAL NAIL SPLINT E. OLAYINKA OGUNRO, MD, FACS, Dallas, Texas From the Charlton Methodist Hospital; and the University of Texas, Health Science Center, Dallas, Texas. Reprinted from THE JOURNAL OF HAND SURGERY, St. Louis Vol. 14A,. 2, Pt. 1, pp , March, 1989 (Copyright 1989, by The C.V. Mosby Company) (Printed in the U.S.A.)

2 External fixation of injured nail bed with the INRO surgical nail splint The use of the nail as a splint Is desirable in the management of acute nail bed Injuries. However, when the nail plate Is destroyed and during secondary reconstruction of the nail bed, the nail Is not available for use as a splint. Several substitutes, notably silicone sheet have been used, but without much success. The INRO surgical nail, with qualities similar to the nail splint was developed for use as a substitute. During the period of study from 1983 to 1985, 89% of patients had good results. (J HAND SURG 1989;14A: ) E. Olayinka Ogunro, MD, FACS, Dallas, Texas Publications by Zook and associates "' clarified the anatomy of the paronychium and stressed the importance of anatomical reconstruction of the nail bed. Contributions by Flatts. 6 McCash, 7 Shiller, 8 and Asbell and colleagues, 9 directed attention to the proper management of nail bed injuries. Edstrom 10 and Daniller wrote of the continued frustration of the management of these injuries. The INRO surgical nail splint was developed as an alternative to the silicone sheet that has several disadvantages (Fig. 1, A and B). lt tears too readily when From the Charlton Methodist Hospital; and the University of Texas, Health Science Center, Dallas, Texas. Received for publication June 9, 1986; accepted in revised form June 9, Although none of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article, benefits have been or will be received but are directed solely to a research fund, foundation, educational institution or other non-profit organization with which one or more of the authors are associated. Reprint requests: E. Olayinka Ogunro, MD Bolton Boone, Suite 105, DeSoto, Texas sutured, it is difficult to seat finnly in the eponychial fold because of its rubbery nature, and it does not possess the rigidity or the curves of the natural nail. Indeed Zook 1 noted in his study that it "was difficult to maintain in the nail fold during the healing phase, perhaps adversely affecting our results." The nail splint was therefore developed with qualities similar to the natural nail for use when it is not available for reconstruction. The artificial nail is made of polypropylene, which provides the necessary rigidity. It is nontoxic, extremely stable, nonreactive, and nonfibroblastic. The impact strength affords considerable resistence to breakage and protects the extremely sensitive nail bed from further trauma during the healing phase. When the splint is sutured in place it provides a finn fixation for the nail bed and encourages the continuation of Kligman's 12 vector forces distal to the eponychium (Fig. 2, A). It molds the healing nail bed, which in tum, acts as a template for the regenerating nail. The newly fonned nail cells are forced to assume a more horizontal and fiat course and adhere to the nail bed (Fig. 2, B). The splint prevents granulation tissue ingrowth from the eponychium or the paronychium. Once the nail has grown to approximately 4 mm or more and 136 THE JOURNAL OF HAND SURGERY

3 Vol. 14A,. 2, Part 1 March 1989 Surgical nail splint 23? Fig. 1. A, Dorsal view. Drainage holes found to be necessary in prevention of hematoma formation. B, Lateral view. Dorsal Root-Shine Dorsal Roof Kligmans Vector Force Ventral Floor-Intermediate nail 0 Ventral Floor Fig. 2. A, Kligman's vector force. A Kligman's vector force is the result of forces from the sulcus and the eponychium acting on the regenerating nail to direct it distally and horizontally. Distal to the eponychium the vector force becomes weaker because of the absence of the eponychial component. This is more evident in the presence of nail bed injury when the healing nail bed develops its own vertical force. B, The nail splint enhances the effect of the eponychium distally and thereby encourages the continued activation of the vector force distal to the eponychium. The splint also exerts a direct compressive force on the healing nail bed. This force or molding factor is what molds the injured nail bed. The combined effect of these encourage the regenerating nail to be flat and adherent. the nail bed has healed, normal growth appears to be maintained when the splint is removed. Operative procedure Fractures of the distal phalanx are reduced. The nail bed and matrix are repaired anatomically with. 6-0 vicryl. The proximal sutures are applied as shown in Fig. 2, B. using the horizontal drainage holes of the splint, care being taken to avoid suturing the germinal matrix. Traction on the suture will seat the splint firmly in the sulcus (Fig. 2, B), distal sutures are then applied. A dressing is applied for a week. The finger is evaluated

4 238 Ogunro The Journal of HAND SURGERY ~ I "i /!.I Fig. 3. (Case 12) A, Multiple avulsion injuries of nail bed and germinal matrix, with comminuted fracture of the distal phalanx. B, At 9 months good result obtained (arrow). Table I Sire of injury Case II Palmar I Dorsal I Proximal I Middle Patie/11 Age Sex Digit fold fold J. F. 18 M Rtll Rtlll Rt IV C. W. 27 M Rtll K. T. 22 M Rt I K. H. 20 M Lilli M Rt Ill S. B. 17 M Rtl A. D. 34 M RtV D. F. 19 F Rt III C. H. 16 M Lt I J. P. 21 M Lt 111 ]. s. 41 M Rtl T. R. 43 M Ltl J. S. 19 M Ltl E. I. 12 F Rt Ill Y. I. 21 M Ltlll J. G. 23 M Rt IV R. W. 26 M Lt Ill M. C. 35 M Rt I I Distal 113

5 Vol. 14A,. 2, Part I March 1989 Surgical nail splint 239 weekly and use of the splint is stopped when the nail bed has healed. Material There were 18 patients with 20 nail bed injuries; 16 males, with 18 fingernails, and 2 females, with 2 fingernails. The age range was 12 to 43 years, with a mean of 24 years. The injuries were categorized as in ZooJ(4 (Table I). Patients seen initially with an intact nail plate were excluded. In more than 90% of the cases injuries were caused by industrial accidents. Case no. 2 required a large bone graft to reconstruct the distal and middle phalanx, which were completely destroyed. In cases. 3, 13, and 17, the nail splint served additionally as a means of attachment for the flap. Results Very strict criteria were used for grading the results. The three grades wen~: good, fair, and poor. A nail graded good must look like the corresponding uninjured nail on the contralateral hand (Fig. 3, A and 8 ; Fig. 4, A through C). It must have regained its size, shape, and smoothness and growth. Fair results were characterized by a nail that did not regain its original size, shape, or smoothness; however, growth was normal. Nails that did not regenerate were placed in the poor category. One patient was lost to follow-up (Table 1). Fifteen out of 17 patients, or 17 out of 19 fingers demonstrated good results. One patient with a fair result removed his splint at 14 days. One patient with a poor result was operated on 19 days after injury. In one patient (case 2) an infected hematoma developed below the splint. This was treated by irrigation with peroxide using a 22-gauge needle inserted beneath the splint. Subsequent splints were modified with four perforations to allow adequate drainage. There were no allergic reactions, personal intolerance, or fracture of a splint. Discussion Eighteen cases of severe nail bed injuries were studied using the splint as a nail substitute. ne of these patients were seen initially with their original nail or portions thereof that could have been used as a splint. It was noted that the splint functioned like the natural nail and protected the highly tender and sensitive nail bed from painful stimuli. It eliminated adherence of the nail bed to the dressing, thus making a dressing change more tolerable. It helped to reduce pain after avulsion injuries of the nail plate and nail bed and prevented bifid nail formation by the elimination of collagen tissue ~ ~ Type of Associated Date of Date of injury injuries injury surgery Avulsion Fracture 11/16/83 11/16/83 Laceration Distal Laceration Phalanges Avulsion Distal phalanx 2/ 3/84 2/ 3 / 84 Crush Pulp loss 2 / 14/84 2/14/84 Avulsion Distal phalanx 3/5/84 3/ 12/84 Laceration Distal phalanx 3 / 26/ 84 3/ 26/84 Avulsion 4 / l / 84 4/ 3/84 Stellate 4 / 27 / 84 4/ 30/84 Avulsion Distal phalanx Avulsion Distal phalanx 6/8/84 6/27/84 Avulsion Distal phalanx 6/23/84 6/23/84 Avulsion 5114/84 5/14/84 Stellate Distal phalanx 11 / 17/84 11 / 17 / 84 Avulsion Pulp loss 3/2/85 3/ 2/85 Avulsion Distal phalanx / 22/ 85 Stellate Tuft fracture 3/ /21/85 Laceration Mallet finger 416/85 4!6185 Avulsion Distal phalanx 8/9/85 8/9/85 Avulsion Distal phalanx 4/16/85 4/22/85 Associated Follow-up Surgery surgery in momhs Results Repair/splint 9 Good Repair/ splint 9 Good Repair I splint 9 Good Repair I splint ORIF/ bone graft 18 Good Repair I splint Pedicle flap II Good Repair/ splint 9 Good Repair/ splint 7 Good Repair/ splint 16 Good Repair/ splint 8 Good Repair I splint 2 lost Unknown Repair I splint ORIF I phalanx 14 Poor Repair/ splint 9 Fair Repair I splint 9 Good Repair I splint 9 Good Repair I splint Pedicle flap 5 Good Repair I splint 8 Good Repair I splint 8 Good Repair/ splint 4 Good Repair I splint V-Y flap 6 Good Repair I splint 12 Good

6 240 Ogunro The Journal of HAND SURGERY y Fig. 4. (Case 18) A, Extent of injury to the matrix and nail bed after removal of the coagulated blood and granulation tissue at I week after injury. B, The medial portion of the matrix that was too fragmented to repair was simply reduced and splinted. C, Final result obtained after complete healing (arrow). ingrowth from the nail fold into the nail bed or germinal matrix. It helped to maintain the contour of nail bed while it was healing and eliminated adhesion of eponychial fold to the nail bed thus encouraging the regeneration of germinal matrix. The regenerated nail was not cornified. Cornification occurred I to 2 weeks after exposure. The regenerated nail was thin, the cells migrated distally and horizontally from the vector force created by the nail fold and the splint. In acute nail bed injuries with associated fractures of the nail plate that rendered it unsuitable for reconstruction, the FDA-approved splint was found to function like the natural nail and served as a suitable substitute. REFERENCES I. Zook EG, Guy RJ, Russell RC. A study of nail bed injuries: causes, treatment and prognosis. J HAND SuRa 1984;9A:

7 Vol. 14A,. 2. Part I March 1989 Surgical nail splint 2. Zook EG, Van Beck AL, Russell RC, et al. Anatomy and physiology of the perionychium: a review of the literature and anatomical study. J HAND SuRG 1980; 6: Zook EG. The perionychium: anatomy, physiology, and care of injuries. Clin Plast Surg 1981;8: Zook EG. Injuries of the fingernail. In: Green DP, ed. Operative hand surgery. New York: Churchill Livingstone, Flatt AE. Nailbed injuries. Br 1 Plast Surg 1955;8: Flatt AE. Minor hand injuries. 1 Bone Joint Surg 1955; 378: McCash CR. Full nail grafting. Br 1 Plast Surg 1956; 8: Shiller C. Nail replacement in fingertip injuries. Plast Reconstr Surg 1957;19: Asbell TS, Kleinert HK, Putcha S, et al. The deformed fingernail, a frequent result of failure to repair nail bed injuries. 1 Trauma 1967;7: Edstrom E. Correspondence News Letter. American Society of Surgery of the Hand II. Dan iller Avron. Correspondence News Letter Kligman AM. Why do nails grow out instead of up? Arch Dermatol 1961;84:313-5.