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Three Part Question

In [a patient with an acute traumatic subungual haematoma] is [an open nail bed repair or subungual trephination] more [effective ]

Clinical Scenario

A sixteen year old patient presents to the emergency department following a crush injury, with an acute traumatic subungual haematoma of the finger. The nail margin and nail are intact. There is an undisplaced fracture of the distal phalanx present.

Search Strategy

The search strategy included a search of the Cochrane Central Register of Controlled Trials, AMED (Allied and Complementary Medicine) 1985 to January 2011, EMBASE 1980 to 2011 Week 03, HMIC Health Management Information Consortium 1979 to November 2010, Ovid MEDLINE(R) Daily Update January 25, 2011, Medline and Medline Non-Indexed Items, PsycINFO 1806 to January Week 4 2011, Journals @ OVID: full-text electronic journals, Journals @ OVID: database for searching, British Nursing Index and Archive 1985 to January 2011, Ovid OLDMEDLINE(R) 1946 to 1965 The search was undertaken in February 2011.
The following search strategy was used to identify relevant studies in Medline (Ovid)

1. nailbed injur*.mp.
2. nailbed laceration*.mp
3. nailbed trauma.mp
4. nailbed surgery.mp
5. nailbed treph*.mp
6. fingernail injur*.mp
7. fingernail laceration*.mp
8. fingernail trauma.mp.
9. fingernail surgery.mp
10. fingertip injur*.mp
11. fingertip trauma.mp
12. fingertip laceration*.mp
13. fingernail treph*.mp
14. subungual haematoma*.mp
15. subungual treph*.mp
16. subungual injur*.mp

The following search was also carried out using MeSH (the U.S. National Library of Medicine's controlled vocabulary used for indexing articles for MEDLINE/PubMed): "Nails"[Mesh] AND "Wounds and Injuries"[Mesh].

The searches resulted in 417 papers being selected, after duplicates had been excluded. Of these 63 were relevant to the general topic area. However of these 63 relevant papers only four met the specific inclusion criteria.

Search Outcome

Four studies met the inclusion criteria.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Farrington GH 1964 UK	Subungual haematomas in adults and children including fractures	Prospective comparative study of different methods of trephination	7% rate of abnormal nail growth and an infection rate of 4.2%		No group with open nail bed repair for comparison
Seaberg DC, Angelos WJ, Paris PM. 1991 USA	Subungual haematomas in adults and children including fractures	Prospective observational study of nail trephination	All normal nails at final follow up, no complications		No group with open nail bed repair for comparison
Roser SE, Gellman H 1999 USA	>25% subungual haematoma in children with intact nail margin	Prospective comparative study of trephination versus open nail bed repair	No difference in outcome between trephination and open nail bed repair, no infections.	Significantly higher costs for nail removal group (>4X).	Some patients refused trephination
Meek S, White M 1998 UK	Subungual haematomas including fractures	Retrospective case series of nail trephination	Generally good outcomes, infection rate of 4.1%		Retrospective and no group of open nail bed repair for comparison

Comment(s)

Final nail cosmesis does not appear to be affected by the mode of treatment. The significantly higher costs associated with nail removal and nail bed exploration mean that this treatment cannot be justified ahead of subungual trephination in the management of the acutely painful traumatic subungual haematoma with an intact nail and nail margin. If the subungual haematoma is not acutely painful then no treatment at all may be necessary. The presence of a distal phalangeal fracture does not mean that nail bed repair is obligatory, providing this fracture is minimally displaced.

Clinical Bottom Line

There is insufficient evidence to justify nail removal and nail bed exploration in patients who present with the acutely painful traumatic subungual haematoma with an intact nail and nail margin, even in the presence of a distal phalangeal fracture.

References

1. Farrington SUBUNGUAL HAEMATOMA--AN EVALUATION OF TREATMENT. British medical journal. 1964; 1(5385): 742-4.
2. Seaberg DC, Angelos WJ, Paris PM. Treatment of subungual hematomas with nail trephination: a prospective study. Am J Emerg Med. 1991; 9(3): 209-10.
3. Roser SE, Gellman H Comparison of nail bed repair versus nail trephination for subungual hematomas in children. Journal of Hand Surgery. 1999; 24(6): 1166-70.
4. Meek S, White M Subungual haematomas: Is simple trephining enough? Journal of Accident and Emergency Medicine. 1998; 15(4): 269-71.