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Surgeons Urge New Approach to Nail Bed Injuries

A new approach to managing paediatric nail bed injuries could significantly cut NHS costs while maintaining similar rates of infection and cosmesis ratings, according to a new study from the University of Oxford.

Researchers from the Nail bed INJury Analysis (NINJA) Collaborative Group said that nail bed injuries are the most common hand injury in children, typically caused when a fingertip is crushed in a closing door. This happens so often, that it was the subject of an injury-prevention information campaign by the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) in 2017.

The injury can result in displacement of the hard fingernail (nail plate) and laceration of the underlying soft nail bed. Fingertip injuries can present with subungual hematomas, simple or stellate lacerations, crush, or avulsion injuries, often with associated fractures or tip amputations. They can lead to profound functional and cosmetic impairments if not appropriately managed, but optimal management of each of these injuries is controversial, which has led to "nonuniformity of clinical practice". 

10,000 Operations per Year – But No Evidence

In many cases, surgery is performed to repair the underlying nail bed tear; it is estimated over 10,000 such operations are performed in the UK each year. However, the team noted, a Cochrane review had found no randomised trials on nail bed repair type and, therefore, concluded there was "a lack of evidence to inform key treatment decisions in the management of children’s fingertip injuries".

There are two surgical options, the researchers said, either surgically removing the nail plate, suturing the nail bed laceration and replacing the nail plate on the injured nail bed after the operation, or discarding the nail entirely following repair. Currently, 96% of surgeons report replacing the nail, but the NINJA group questioned whether this approach actually made a difference to infection rates, and whether it was cost-effective compared with throwing the nail away.

Many Papers on How to Replace the Nail, But None on Why 

First author Abhilash Jain, associate professor of plastic and hand surgery at the Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences at Oxford explained: "The rationale behind re-attaching the nail is that it protects the repair, reduces infection, and is less painful when the dressings need to be changed. However, there was no evidence to support this practice, and while many papers have been published explaining how to put the nail back, there weren't any telling you why you should put it back."

Hoping to close the knowledge gap, researchers performed a multicentre, pragmatic two-arm parallel-group superiority randomised controlled clinical trial in 451 children aged under 16 years recruited between July 2018 and July 2019 from 20 NHS hand surgery units within 48 hours of presentation with a nail bed injury believed to require surgical repair.

The study involved 100 different surgeons across the UK and all children had injury to a single finger. They were excluded if they had: an infected injury, pre-existing nail disease or deformity in the injured or contralateral finger, a distal phalanx fracture requiring fixation, amputation, loss of part or all of the nail bed requiring reconstruction, or multiple nail bed injuries. 

No Differences in Surgical Site Infections or Appearance

The children were randomised 1:1 into groups either replacing or discarding the nail following nail bed injury repair. Key findings, published in the British Journal of Surgery, showed no statistically significant difference between the two interventions in the primary outcome of the number of surgical-site infections at around 7 days. Furthermore, on follow up at 4 months, 3.5% of children in the group that had nails replaced had infections, compared with 0.9% for the nail discarded group.

In addition, fingernail cosmetic appearance was assessed using the Oxford Fingernail Appearance Score at final follow-up, a minimum of 4 months and up to 12 months after randomisation, and again there was no significant difference in cosmetic appearance between the treatment groups.

NHS 'Could Save £720,000 Each Year'

The researchers also performed a cost-effectiveness analysis that has been separately accepted for publication, also published in the British Journal of Surgery. They concluded that discarding the nail when treating these children would save the NHS £75 per patient. Co-author Dr Helen Dakin, university research lecturer at Oxford Population Health’s Health Economics Research Centre concluded: "By discarding the nail and making operations across the UK shorter and simpler, the NHS could save £720,000 each year."

Prof Jain said the research "paved the way for many more, and bigger trials in the field". He added: "The response to the trial when we started was amazing. We were able to engage surgeons and hospital units who had never been involved in trials before, particularly with children. There was great coordination, and we were able to deliver cheaply and ahead of schedule. We've since seen a massive increase in plastic and hand surgery clinical trials that have helped change the landscape for patient care."

Asked to comment by Medscape News UK, consultant plastic surgeon and BAPRAS spokesperson James Henderson said: "This is a great example of the excellent research that is being undertaken in hand surgery by consultants and trainees in Plastic Surgery in the UK, who have developed an outstanding network.

"We hope that surgeons adopt the recommended approach of not replacing the nail, whilst carefully auditing results to ensure continued good outcomes for patients. Any cost saving is worthwhile for the NHS, and this may prove easier for patients as well. There may be some indications where surgeons feel that the nail plate, or an alternative splint is necessary – for example if there is a fracture or damage to the nail fold – and we are confident that our surgeons will treat each case with the patient’s best interests at heart, whilst also considering the implications for the NHS and other patients in mind."

The study was funded by the National Institute for Health and Care Research (NIHR) and supported by the NIHR Oxford Biomedical Research Centre. The authors declare no conflict of interest.