In a world of doors, truck beds, furniture, and other finger-crushing nuisances, emergency department visits for injuries involving the distal digits are common. Injuries range from tuft fractures, to degloving injuries, to all manner of nail and nailbed derangement.
Perusing any textbook or online resource will typically advise some manner of repair, including, but not limited to, replacing an avulsed nail back into the proximal nail fold and securing it in place. If the avulsed nail is not available, recommendations include placing a bit of foil into the proximal nail fold. The general idea being that failure to do so will irretrievably scar the germinal matrix, resulting in some disfigured and mutant nail growth.
The NINJA trial tests whether this dogma is valid – and, rather unsurprisingly, finds it is not.
In this trial, children with finger nail and nailbed injuries requiring surgical repair were randomized, at the conclusion of the injury repair, either to replacement of the nail (or foil) into the nail fold, or to discard the nail and simply leave on a non-adherent dressing. The “c0-primary” outcomes were cosmetic appearance of the nail (using the Oxford Fingernail Appearance Score) and surgical-site infection at 1 week follow-up.
The majority of the 451 children involved were aged younger than 6 and most were crush injuries resulting in avulsion of the nail plate. The primary outcomes were no different between groups – 5 and 2 surgical-site infections in the “nail replacement” and “nail discarded” groups, respectively, and median OFNAS score was 5 (the highest score) in each group. Lest the trial be accused of just failing to demonstrate a difference favoring the “nail replacement” group, it was actually the “nail discarded” group having a non-significantly more favorable distribution of cosmetic scores.
When suggesting these results are unsurprising, it’s rather just a perspective many clinical encounters in the emergency department are “over-medicalized”, and receive unnecessary tests or treatment simply due to the spectrum bias associated with acute care. Most healthy human substrate is capable of healing from minor injury in a satisfactory fashion; hopefully, these results further inform the care of children with finger nail injuries, and, may be reasonably generalized to other nails and healthy adults.
One thought on “End Nail Dogma”
Comments are closed.