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Use of Modified Tension Band Sutures for Fingernail DisruptionsFrom the Patankar’s Hand & Limb Reconstruction Clinic, Chembur, Mumbai, Maharashtra, India Correspondence: Hemant S. Patankar, MS (Orth), Patankar’s Hand & Limb Reconstruction Clinic, 204, Garodia Market, Plot 8-A, D.K. Sandu Road, Chembur, Mumbai 400 071, Maharashtra, India. Tel.: +91 22 25286160, 25585121, 25565112. E-mail:hand{at}vsnl.com,drhemant.patankar{at}gmail.com.
A series of 66 patients, aged between 1 and 70 years, with 70 disruptive injuries to finger nails was reviewed. The injuries were treated by cleaning of the finger, evacuation of haematoma and anatomical replacement of the nail plate, or a substitute, which was secured with a modified dorsal tension band suture without formal repair of the nail bed. K-wire fixation of the distal phalanx was employed only in the event of displaced fracture of the distal phalanx, complete absence of the nail plate and laceration extending to the distal pulp. This simple method, which bypasses the injured and friable, but vital nail structures resulted in uncomplicated reformation of the normal nail plate in all of the cases. Removal of the nail plate and formal repair of the nail bed is not necessary in any age group with finger nail disruptions.
Key Words: tension band suture • finger nail • disruptions • avulsions Finger tip injuries can result in varying degrees of disruption of the nail plate and/or nail bed. The recommended treatment of injuries of the nail is a meticulous repair of the nail bed after removal of the nail plate. This is preceded by stabilisation of any distal phalangeal fracture and may also include repair of the finger pulp. Lastly, the nail plate, or a stent substitute is repositioned anatomically in the nail fold and sutured to the hyponychium and the proximal nail fold (Al Qattan et al., 2003; Bindra, 1996; Elbeshbeshy and Rettig, 2002; Green and Rowland, 1991; Richards et al., 1999; Rosenthal, 1983; Stevenson, 1992; Zacher, 1984; Zook and Brown, 1993). In this paper, a series of 66 patients with 70 fingertip disruptions were treated by anatomical reposition of the nail plate, or a stent substitute, under the nail fold and securing it with a modified dorsal tension band suture without formal repair of the nail bed.
Between February 1999 and September 2005, 70 fingertip injuries including injury to the nail bed in 66 patients were treated. The injuries included 55 cases of partial nail avulsion, seven cases of complete nail avulsion of which six patients had no available nail, and four cases of sharp injury to the nail plate. Nine fractures had occurred at the level of the middle or proximal third of the distal phalanx and the remaining 61 were tuft fractures. The patients included 18 women and 48 men of mean age 22.9 (range 1–70) years. The patients were followed up for a mean of 15 (range 4–36) months. Cases of subungual haematoma without nail avulsion, or disruption, and those with distal tissue loss, i.e. amputations, were excluded from the study.
The patient was anaesthetised using general anaesthesia in children and local anaesthesia in adults. A tourniquet was applied after elevation of the hand. The hand was thoroughly cleaned and draped. In cases in which the nail was not completely avulsed but just dislocated from the proximal nail fold, the nail was not removed from its residual attachment to the nail bed. Haematoma was completely evacuated and the visible undersurface of the nail was irrigated with a jet of saline from a syringe. The undersurface of the nail was not scraped free of tissue. The nail fold was cleaned and opened gently with a small blunt elevator and the nail plate repositioned anatomically and secured in place with a modified dorsal tension band suture technique (Fig 1a) using 4-0 to 6-0 non-absorbable, unbraided Ethilon (Ethicon, Division of Johnson and Johnson Ltd., Aurangabad, India) on an atraumatic cutting needle. Proximally, a suture was placed at least 6 to 8 mm proximal to the nail fold in order to avoid injury to the germinal matrix. The suture was passed transversely through the skin, superficial to the repositioned nail plate and the underlying germinal matrix. The needle is then carried distally crossing, the midline of the finger dorsally. The distal pass of the suture was made transversely through the finger pulp just distal to the nail hyponychium. With an assistant maintaining the reduction of the nail plate, or stent, the suture was then tensioned to just short of skin blanching and tied resulting in a dorsal Figure-of-8 loop (Fig 1b). This dorsal tension band suture results in adequate approximation of any fracture of the distal phalanx, the nail bed and the skin edges on either side of the nail, avoiding the use of additional sutures through the crushed soft tissues of the nail bed, the hyponychium and the proximal nail fold. The replaced nail plate is believed to prevent adhesion of the nail fold to the proximal nail bed (Fig 2).
In cases of severe injury, the finger nail may be completely avulsed with laceration of the nail bed, lateral nail fold and finger pulp and fracture of the tuft, or shaft, of the distal phalanx. In these cases, the fracture was reduced and stabilised with a K-wire, the position of which was verified with a C-arm image intensifier. The nail bed was palpated for sharp spikes of bone, which were reduced when present. The lacerated ends of the nail bed were gently spread out with a blunt instrument such as the proximal end of the knife handle and positioned as anatomically as possible over the dorsum of the distal phalanx. However, no attempt was made to suture them. The nail plate (if available) and the nail fold were washed and cleaned. The nail plate, or a stent, was then replaced anatomically under the proximal nail fold and secured in place with a variation of the modified tension band suture technique (Fig 1c). In such cases, the distal cut end of the K-wire served as an anchor point for the distal suture as the tissues were often too damaged to hold any suture (Figs 3 and 4). This technique can be used in cases with associated pulp reconstruction using skin graft or flaps.
In cases of a linear wound due to a sharp instrument, the nail plate, nail bed and the distal phalanx are injured in one plane. The wound generally extends laterally onto the lateral nail fold and involves the pulp to a variable extent. In such situations, the haematoma was washed off and the finger cleaned. Without removing the nail plate, the cut ends of the nail plate with the nail bed and the bone were approximated with the modified tension band suture. An additional suture through the centre of the existing suture in the midline was placed for augmentation of the repair (Fig 1d). One, or two, fine sutures were, sometimes, used in addition in the pulp, depending upon the condition of the soft tissues (Fig 5).
Retrograde intramedullary K-wire fixation was used for irreducible fractures of the tuft, displaced fractures of the shaft with proximal nail bed lacerations, absence of an intact skin bridge on the volar aspect of the digit and in cases of severe crushing of the soft tissues of the pulp with avulsion, or absence, of the nail plate and in cases of pulp reconstruction using a skin graft or flap. Postoperatively, a dorsal gutter splint was applied over a non-adherent finger dressing and the hand was elevated and splinted in the functional position. The wound was inspected 2 days after surgery and the dressing was reduced to include only the finger involved, to allow active mobilisation of the hand. The tension band suture and the K-wire were removed in the out-patient clinic 3 weeks later. The nail or its substitute usually stayed attached to the digit for several weeks more, until dislodged spontaneously by advancement of the newly forming nail.
This technique has been used for the treatment of 70 fingertip injuries in 66 patients who presented with dorsal tissue disruptions (Table 1).
At a minimum follow-up of 4 months after surgery, mean 15 (range 4–36) months, no complications were noted as a result of the modified tension band suture either at the nail fold or at the finger tip. Deformity in the form of shortening and deviation was noted in two finger nails following severe soft injury and comminuted fracture of the distal phalanx (Fig 3b and d). There was no deformity of the nail in the remaining fingertips. Although radiographic confirmation of the union was not obtained in each case, the fractures were clinically stable in all cases at the time of the final follow-up.
Finger tip injuries, particularly those causing dorsal tissue disruptions frequently disrupt the finger nail. Blunt injuries to the finger tip may result in dislocation of the intact nail plate from the nail bed to a variable extent and the proximal end of the nail plate may come to lie on the dorsum of the proximal nail fold. In other instances, there is complete avulsion of the nail plate, which may be missing. In approximately 50% of cases, there is also a fracture of the tuft, or shaft, of the distal phalanx with laceration of the nail bed, which is displaced with the osseous fragments (Zook and Brown, 1993). In these cases, there is often associated laceration of the lateral nail folds and volar finger pulp. The lacerations extend variably on one, or both, sides from the lateral nail fold onto the volar aspect of the pulp. Sharp injuries frequently result in a linear wound involving the nail plate, nail bed and the distal phalanx. This wound generally extends laterally onto one, or both, lateral nail folds and may involve the volar pulp to a variable extent. A number of permutations of injuries of the various tissues are recognisable from simple nail plate avulsion to severe crushing of all dorsal tissues. The recommended treatment of dorsal disruptions of the finger tip is evacuation of the subungual hematoma followed by a meticulous repair of the nail bed, after complete removal of the nail plate. This is coupled with reduction and stabilisation of any fracture of the distal phalanx and approximation of the finger pulp. The nail plate, or a stent substitute, is then repositioned anatomically under the proximal nail fold and sutured to the hyponychium and the proximal nail fold (Al Qattan et al., 2003; Bindra, 1996; Elbeshbeshy and Rettig, 2002; Green and Rowland, 1991; Richards et al., 1999; Rosenthal, 1983; Stevenson, 1992; Zacher, 1984; Zook and Brown, 1993). The repositioned nail plate, or stent, is believed to prevent adhesion formation between the nail fold and the germinal matrix proximally by keeping the nail fold open, so permitting growth of the normal new fingernail (Al Qattan et al., 2003; Rosenthal, 1983; Stevenson, 1992; Zook and Brown, 1993). Numerous techniques have been described to secure the nail plate. These have usually involved suturing the nail, either proximally through the nail fold or distally onto the hyponychium (Elbeshbeshy and Rettig, 2002; Green and Rowland, 1991; Rosenthal, 1983; Stevenson, 1992; Zook and Brown, 1993). They mostly involve needle and suture passage through the already traumatised tissues, leading to further damage (Richards et al., 1999). Passage of the needle through the intact nail plate itself can also be difficult. Often, these sutures do not provide a firm bond between the nail and the nail bed. Occasionally, there may not be any normal adjacent soft tissue available, to which the nail can be sutured adequately. Foucher et al. (1984) described a method of nail fixation by passage of a needle through the nail plate and nail bed, then leaving the needle in place postoperatively, which uses the principle of tension band fixation. The use of an acrylic adhesive is also appealing (Richards et al., 1999). There is a firm natural bond between the nail plate and the sterile matrix of the nail bed and between the sterile matrix and the periosteum of the distal phalanx (Rosenthal, 1983; Zacher, 1984; Zook and Brown, 1993). The smooth under-surface of the nail provides a biological template for healing of the nail bed in the anatomical position and results in formation of a normal finger nail (Bindra, 1996; Green and Rowland, 1991; Rosenthal, 1983; Zook and Brown, 1993). Several authors have considered that removal of the attached nail to achieve primary repair of the nail bed is not necessary and not to be recommended (Brown, 1973; Lammers and Trott, 1998; Selbst and Magdy, 2001; Smith and Rider, 1935). There are also reports of indifferent, or poor, results following conventional nail bed repair (DaCruz et al., 1988; Roser and Gellman, 1999). In this series, seven patients had complete avulsion of the nail plate exposing the lacerated nail bed. In four patients with linear wounds, the nail bed injury was obvious but it was not accessible for repair as the nail plate was not separated from the nail bed distally. In the majority of the patients (55 patients with 59 finger tip injuries), nail bed injury was suspected due to partial avulsion of the intact nail plate from the proximal nail fold (Rosenthal, 1983), but it was not visible due to the distally attached and intact nail plate. In all cases in the series, nail plates which were still attached were left intact, preserving the natural bond between the nail plate and bed, and the nail plate, the nail bed, distal phalanx and the finger pulp approximated as one unit by a simple method originally described by Bindra (1996), using a Figure-of-8 suture without formal repair of the nail bed. This suture technique, used by these authors originally to secure the nail in position after repair of the nail bed, avoids any need to place sutures into the weakened tissues of the nail bed. In more severe injuries with disruption of the distal skin and soft tissues, a longitudinal K-wire, inserted retrograde into the distal phalanx, and serves not only to stabilise the distal soft tissues but may be used as the anchor point for the distal suture. As the proximal suture is taken well away from the proximal nail fold, this technique avoids any injuries to the proximal nail fold. Additional tension banding is possible through the visible central part of the suture. The latter is particularly useful in linear injuries causing transverse fractures of the nail plate. The finger nail serves as a natural splint for fractures of the distal phalanx (Bindra, 1996; Brown, 1973; Elbeshbeshy and Rettig, 2002; Richards et al., 1999; Roser and Gellman, 1999; Smith and Rider, 1935; Zook and Brown, 1993) and, in cases of comminuted fractures of the tuft, it is neither feasible nor necessary to reduce them (Brown, 1973; Green and Rowland, 1991). The anatomical repositioning of the nail plate and its natural bond to the distal nail bed, coupled with the secure bond provided by the modified tension band suture technique, helps to approximate the fracture fragments and the nail bed. The anatomical repositioning of the nail plate under the proximal nail fold prevents over reduction of the distal tissues in case of tuft fractures. Therefore, this technique can be used in comminuted fractures of the tuft of the distal phalanx. Additionally, the secured nail plate prevents formation of subungual haematoma and also reduces pain and tenderness at the finger tip (Zook and Brown, 1993). Despite the above, two cases in our series with comminuted fracture of the shaft of the distal phalanx healed with shortening. The K-wires were inadvertently removed before confirmation of fracture union. These deformities were attributed to the comminuted nature of the injury and inaccurate reduction of the fracture. Therefore, care must be taken in respect of accurate reduction, stable fixation and confirmation of union before K-wire removal in fingertip injuries with comminuted fractures of the shaft of the distal phalanx. Fortunately, these two cases suffered no functional disability despite shortening of the nails.
Manuscript received March 15, 2006. Accepted for publication May 31, 2007.
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Journal of Hand Surgery (European Volume), Vol. 32, No. 6,
668-674 (2007)
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Abstract
PATIENTS AND METHODS
