Ava Monroe
Suturing through a fingernail is a complex procedure that requires medical expertise. It is often performed in emergency departments to treat lacerations and crush injuries to the fingertip. The process involves repairing the nail bed, which lies underneath the nail plate, and can be done using sutures or tissue adhesive glue. When suturing, it is recommended to first sew through the soft tissue and then exit through the nail to prevent foreign body granuloma formation. A sturdy needle and large suture are necessary, and pre-soaking the nail in warm water can make it easier to suture.
| Characteristics | Values |
|---|---|
| Procedure | Suturing a nail bed laceration |
| Tools | Sturdy needle, suture, scalpel, finger tourniquet, irrigation liquid, Betadine, towel, gauze, adhesive glue, Ace bandage |
| Preparation | Clean the wound, apply anesthesia, separate and remove the nail plate from the nail bed, irrigate the area to prevent infection |
| Suturing Technique | Start with soft tissue, exit through the nail, use a transverse figure-of-eight suture, place a knot on the eponychium, add a simple suture at the hyponychium |
| Post-Suturing Care | Splint the finger, follow up with a hand surgeon within 3-5 days |
| Alternative Techniques | Tissue adhesive glue, trephination, figure-8 stitch |
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What You'll Learn
Use a finger tourniquet to aid in hemostasis
Lacerations of the finger can cause severe bleeding due to digital vascularity. This can make it difficult to examine the wound and perform suturing. To control the bleeding, you can apply simple direct pressure over the laceration. Each finger is supplied blood by the radial and ulnar branches of the digital arteries. Hemostasis can be achieved by externally compressing these branches.
A finger tourniquet can be used to aid in hemostasis. To create an elegant tourniquet, you can use a glove. Cut off the finger of a glove and make a small hole at the distal tip of the finger glove. Put this on your own finger, then push and roll the finger glove proximally to create a tourniquet ring. Remove the ring and apply it to your patient's finger. Ensure the hole at the tip of the finger glove is not too big to maximise tourniquet tension. If the tourniquet ring is loose, use the pinky finger part of the glove or select a smaller glove.
The tourniquet has been an essential tool in extremity surgery for many centuries. It provides a bloodless field for visualisation and limits total blood loss. However, it is not without complications. Ischemic damage to muscles, pressure damage to nerves, and the systemic effects of reperfusion limit the duration of its use.
Once bleeding is under control, you can proceed with suturing the nail.
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Irrigate the wound with at least 1 litre of irrigation
When suturing through a fingernail, it is important to irrigate the wound with at least 1 litre of irrigation solution. Wound irrigation is a critical step in wound management and is the greatest intervention to reduce the risk of infection, the most common complication of wounds. Irrigation is the process of washing out a wound before closure to reduce the microbial burden by removing tissue debris, metabolic waste, and tissue exudate.
The patient should be properly positioned, and the nurse should ensure all the required equipment is readily available. The wound bed should be anesthetized before irrigation, and decontamination should be performed by brushing off any dry chemicals. The solution should be prepared in the patient's room, and a waterproof trash bag should be placed near the patient's bed. The top of the bag should be folded down to create a cuff, preventing instruments or gloves from touching the bag's edge.
The patient should be positioned so that the solution runs from the upper end of the wound downward. A waterproof bed pad and clean basin or irrigating pouch should be placed under the area to be irrigated. The irrigation solution should be isotonic, nonhemolytic, nontoxic, transparent, easy to sterilize, and inexpensive. Normal saline is the most commonly used solution due to its safety and physiologic factors, although it may not cleanse dirty wounds as effectively as other solutions.
The nurse should monitor the patient after the procedure and be vigilant for any changes in the patient's vital signs or the status of the wound.
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Use a sturdy needle and large suture
When suturing a fingernail back in place, it is important to use a sturdy needle and a large suture. The needle should be strong enough to penetrate tough tissues. A reverse-cutting needle is ideal for this purpose as it is stronger than a conventional cutting needle and is designed to penetrate tough tissues. A 3-0 or 4-0 needle is recommended for suturing the nail back in place. Before replacing the nail and suturing it back, you can poke a hole through it so that the needle and suture can pass more easily.
The suture should be large, and non-absorbable sutures are recommended for use on the skin. Nylon (Ethilon) and Polypropylene (Prolene) are the primary types of non-absorbable sutures. Absorbable sutures, on the other hand, are dissolved by the body's tissues and do not need to be removed. They are best suited for use under the skin as they produce a pronounced scar if used externally. If absorbable sutures are used, it is important to warn the patient about the probability of increased scarring.
The suture technique recommended for fingernail disruptions with fractures of the distal phalanx is the vertical figure-of-eight tension band suture. This technique involves thoroughly cleaning the wound, reducing the fracture fragments, anatomically replacing the nail plate, and securing it with the vertical figure-of-eight tension band suture. This method is simple, secure, and easily reproducible. It does not require formal repair of injured nail bed structures or fixation of distal phalangeal fractures.
Another method to secure the nail in place is the figure-8 stitch proposed by hand surgeons. This method involves using a transverse figure-of-eight suture through a pre-prepared, wedged nail. This technique achieves pressure proximally and ventrally to secure the nail under the eponychial fold.
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Sew through soft tissue before the nail
When suturing a laceration through the nail bed, it is important to first irrigate the wound with at least 1 litre of irrigation solution. Then, apply a finger tourniquet to the base of the digit to aid in hemostasis. Next, prep the hand with Betadine and towel it appropriately. At this point, you should assess the nail bed.
If you need to remove the nail, use Iris scissors or a periosteal elevator to spread at the hyponychium and advance proximally until the instrument reaches the nail fold. Then, the nail should be able to be easily removed with a hemostat or forceps.
Now, to sew through the soft tissue before the nail, you can use the following techniques:
- Pre-soak the avulsed nail portion in warm water to soften it.
- Pre-drill holes in the nail with an 18-gauge needle to make sewing through the tissue and then out the nail easier.
- Use tissue adhesive glue (e.g. dermabond) to repair the nailbed laceration and secure the nail within the eponychial fold.
Once the area is numb, ensure there is no dirt, debris, or other foreign objects inside the cut before sewing it together. An X-ray may be ordered to help look for remaining debris. The doctor may also remove any dead tissues to help the healing process. They will then pull the edges of the cut together and, for each stitch, loop thread through either side of the cut and tie a knot to hold the wound closed.
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Use tissue adhesive glue or dermabond
Tissue adhesive glue or Dermabond can be used to repair nail bed lacerations and secure the nail in place. This method is an efficient and effective alternative to sutures, saving time and minimising discomfort for the patient. It provides a flexible, water-resistant protective coating and eliminates the need for suture removal.
Dermabond comes in a single-use vial in sterile packaging. It consists of an outside plastic casing with an inner glass ampoule containing 0.5 mL of adhesive that can be applied through the applicator tip. As the adhesive moves through the applicator tip, it mixes with an initiator and begins the chemical change from monomer to polymer. Moisture on the skin's surface adds the final catalyst to create a strong polymer bond that bridges the wound edges.
After cleansing, the wound should be positioned so that excess adhesive does not run off into unintended areas. It is important to note that inadequate wound cleansing and preparation may lead to an increased risk of infection. If an infection is suspected, oral antibiotics can be administered, and the adhesive should be removed to initiate standard wound care measures.
Randomised controlled trials have shown that infection rates are comparable between wounds closed with sutures and those closed with Dermabond. Additionally, a 2008 study found no significant differences in cosmetic outcomes, pain experienced, or functional outcomes between the two methods. However, the study did find that repair time was significantly reduced with Dermabond, taking only 9.5 minutes compared to 27.8 minutes with sutures.
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Frequently asked questions
It is recommended to sew through the soft tissue first and then exit through the nail. This is to avoid the risk of a foreign body granuloma forming in the tissue spaces.
A sturdy needle (3-0 or 4-0) is needed, along with large sutures. Dissolvable sutures are also an option.
Tissue adhesive glue can be used to repair the nail bed laceration and to secure the nail in place. Another option is to use a transverse figure-of-eight suture through a pre-prepared, wedged nail.
Before suturing, irrigate the wound with at least 1 litre of irrigation to prevent infection. Place a tourniquet on the finger at the middle phalanx to aid in hemostasis.
After suturing, wrap the finger and splint the entire finger. Patients should follow up with a hand surgeon within 3-5 days to evaluate for healing and infection.
