• 
• 

Three Part Question

In [patients presenting to the emergency department with nail bed lacerations requiring surgical closure] is [medical adhesive of equivalent efficacy or better than sutures] in terms of [immediate wound treatment and long-term outcome]?

Clinical Scenario

A nine year-old child presentes to the emergency department with a laceration to his nail bed following trapping his finger in a door.

Search Strategy

Web of Knowledge (WoK) database (which searches Web of Science 1899-present, MEDLINE 1950-present, BIOSIS reviews 1926-present and Journal Citation Reports).
Cochrane Library.
References from papers identified in this search.

Search terms: [(Glue OR adhesive OR *cyanoacrylate OR OCA OR Dermabond) AND (suture* OR stitch*) AND ("nail bed" OR subung*) AND (lacerat* OR wound OR cut OR tear)]
PubMed search using terms:
(nail bed repair[Text Word]) AND ((adhesive[Text Word]) OR (glue[Text Word]))
Filters activated: Humans
PubMed search using terms:
(nail bed repair[Text Word])
Google Scholar search using terms
(nail bed repair)

Search Outcome

Web of Knowledge: 4 papers found, 2 relevant: 1 randomised controlled trial (RCT), 1 case series
Cochrane Library: 1 paper found: duplicate of RCT identified on WoK
References: 1 further relevant case series found

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Strauss EJ, Weil WM, Jordan C, Paksima N February 2008 United States of America	40 patients, of age 2-92 years old, with nail bed lacerations presenting within eight hours of injury, where injury was not sustained from bite wounds. 18 repaired with tissue adhesive and 22 repaired with sutures.	Prospective, randomised, controlled trial	Time taken to repair nail bed	Mean time using tissue adhesive: 9.5 mins. Mean time using sutures: 27.8 mins. P<0.0003	Small numbers - study may be underpowered. Heterogenous group of surgeons - differences may be due to the surgeon's ability, as opposed to the method used
			Patient-perceived functional outcome at 6 months (10 point scale)	Tissue adhesive group: mean 9.9; suture group: mean 10. P>0.05
			Patient-perceived cosmetic outcome at 6 months (10 point scale)	Tissue adhesive group: mean 9.8; suture group: mean 10. P>0.05
			Patient-perceived level of pain at 6 months (10 point scale)	Tissue adhesive group: mean 1.1; suture group: mean 1.0. P>0.05
			Physician-perceived cosmetic outcome	Tissue adhesive: 15 excellent, 2 very good, 1 poor. Suture group: 17 excellent, 4 very good, 1 good. P>0.05
Langlois J, Thevenin-Lemoine C, Rogier A, Elkaim M, Abelin-Genevois K, Vialle R 2010 France	30 children, mean age 2.9 years, presenting to hospital within eight hours of injury between November 2008 and February 2009. Total of 31 repairs using tissue adhesive	Prospective case series	Mean operative time	7.7 minutes	This case series has no control for comparison, and uses relatively small numbers. Additionally, no data were collected on long-term outcomes
			Infection at seven days post-repair	Absent in all
			Pain at seven days post-repair	Absent in 16 cases, moderate in 15
			Pain at one month post-repair	Absent in all
			Functional evaluation at one month post-repair	Complete recovery in all
			Patient/family-assessed cosmetic recovery at one month post-repair	Satisfactory in 22 cases
			Surgeon-assessed cosmetic recovery at one month post-repair	Very good in 13 cases, good in 8, mild in 8, fair in 2
			Pain at three months post-repair	Absent in all
			Functional impairment at three months post-repair	Absent in all
			Patient/family-assessed cosmetic result at three months post-repair	Excellent in 30 cases
			Surgeon-assessed cosmetic result at three months post-repair	Excellent in 25 cases, good in 6
Yam A, Tan SH, Tan ABH 2008 Not listed	10 patients with acute lacerations to the sterile matrix without germinal matrix injury. Lacerations repaired with tissue adhesive	Case series	Mean operative time	4.2 minutes	This series didn't include a control, and had very small numbers. The cosmetic appearance of the nails was rated by hand surgeons looking at photos of the nails - not the physical nails; this may not have accurately portrayed the cosmetic appearance
			Cosmetic result at six moths post-repair	Comparable to suture repair

Comment(s)

The one randomised controlled trial suggests that medical adhesive provides results equivalent to sutures when used for treating nail bed lacerations. However, this is a small study (40 patients total, 18 in the intervention group and 22 in the control group), which may have lead to differences existing, but not statisticall significant at the level of α<0.05.

Clinical Bottom Line

Medical adhesive provides more rapid treatment with no apparent long-term detriment, as compared to suturing. However, further evidence is required.

References

1. Strauss EJ, Weil WM, Jordan C, Paksima N A Prospective, Randomised, Controlled Trial of 2-Octylcyanoacrylate Versus Suture Repair for Nail Bed Injuries Journal of Hand Surgery - American Volume 2008; 250-253
2. Langlois J, Thevenin-Lemoine C, Rogier A, Elkaim M, Abelin-Genevois K, Vialle R The use of 2-octylcyanoacrylate (Dermabond) for the treatment of nail bed injuries in children: results of a prospective series of 30 patients Journal of Children's Orthopaedics 2010; 61-65
3. Yam A, Tan SH, Tan ABH Novel method of rapid nail bed repair using 2-octyl cyanoacrylate (Dermabond) Plastic and Reconstructive Surgery 2008; 148e-149e