Correspondence/ American Journal of Emergency Medicine 34 (2016) 307–337 335

Joseph A. Gil, MD^? Steven F. DeFroda, MD Raymond Y. Hsu, MD

Brown University, Warren Alpert Medical School of Medicine Department of Orthopaedic Surgery, Providence, RI

^?Corresponding author. Department of Orthopaedic Surgery Brown University, Warren Alpert School of Medicine

593 Eddy St, Providence, RI 02903

Tel.: +773 551 4083; fax: +401 444 6182

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.11.059

References

1. Kim JK, Kook SH, Kim YK. Comparison of forearm rotation allowed by different types of upper extremity immobilization. J Bone Joint Surg 2012;94(5):455-60.
2. Bong MR, Egol KA, Leibman M, Koval KJ. A comparison of immediate postreduction splinting constructs for controlling initial displacement of fractures of the distal ra- dius: a prospective randomized study of long-arm versus short-arm splinting. J Hand Surg [Am] 2006;31(5):766-70.
3. Mulford JS, Axelrod TS. Traumatic injuries of the distal radioulnar joint. Orthop Clin North Am 2007. http://dx.doi.org/10.1016/j.ocl.2007.03.007.
4. DeFroda SF, Gil JA, Bokshan S, Waryasz G. upper extremity quad splint: indica- tions and technique. Am J Emerg Med 2015;33(12):1818-22.
5. Denes AE, Goding R, Tamborlane J, Schwartz E. Maintenance of reduction of pe- diatric Distal radius fractures with a sugar-tong splint. Am J Orthop 2007;36(2): 68-70.
6. Davis DI, Baratz M. Soft tissue complications of distal radius fractures. Hand Clin 2010;26:229-35.
7. Halanski M, Noonan KJ. Cast and splint immobilization: complications. J Am Acad Orthop Surg 2008;16:30-40.
8. Boyd AS, Benjamin HJ, Asplund C. Principles of casting and splinting. Am Fam Physi- cian 2009;79:16-22.
9. Gannaway JK, Hunter JR. Thermal effects of casting materials. Clin Orthop Relat Res 1983:191-5.
10. Lavalette R, Pope MH, Dickstein H. Setting temperatures of plaster casts. The influ- ence of technical variables. J Bone Joint Surg Am 1982;64:907-11.

Closed traumatic finger tip injuries in patients

with artificial nails: removal of UV gel and acrylic nails?

Traumatic fingertip injuries are exceedingly common and often times very easy to diagnose based on mechanism and visual inspection [1]. The presence of artificial nails, however, can mask the presentation of an underlying nail bed injury. In addition, they can theoretically in- crease the risk of infection in the setting of nail bed laceration over a fracture as artificial nails have been shown to harbor pathogens in a number of studies [2-4]. Although obvious Crush injuries result in marked deformity of the digit, more subtle mechanisms may result in a nail bed laceration that presents solely as a subungual hematoma. This finding can be difficult to evaluate in the setting of an artificial nail. Nail removal or trephination is generally recommended in the set- ting of subungual hematoma of greater than 50% of the nail [5,6]. A pa- tient with a suspected crush mechanism or with a distal phalanx fracture on radiographs should have the artificial nail removed to fully evaluate the extent of the injury.

Physical examination of closed traumatic finger tip injuries should be performed before local anesthetic administration so that a complete neurovascular examination can be performed [6]. First, the finger is inspected for deformities suggestive of fracture or dislocation and the surrounding skin inspected for lacerations or other obvious soft tissue injury. The nail bed and nail plate are inspected visually for evidence of hematoma or laceration. The area of any subungual hematoma found upon physical examination should be estimated as a percentage of the total area of the nail plate. Next, sensation should be tested for

? The authors have no financial disclosures.

light touch or 2-point discrimination along the radial and ulnar borders of the digit for evaluation of the digital nerves. Finally, isolated flexor and extensor tendon function are tested to rule out tendon avulsion or laceration. When testing function of the flexor tendons, active flexion at the distal and proximal interphalangeal joints should be tested in iso- lation to test both the flexor tendon profundus and flexor tendon superficialis, respectively. In cases where visualization of the patient’s nail plate is masked by an artificial nail, the artificial nail should always be removed so that the nail plate and nail bed can be evaluated. In the following paragraphs, we describe techniques for atraumatic removal of commonly encountered artificial nails.

According to the Professional Beauty Association and the Nail Man- ufacturers Council on Safety, proper removal of the UV gel nail is neces- sary to avoid damaging the natural nail [7]. Proper removal involves soaking the nail in an acetone solvent, which dissolves the adhesive and allows of for safe and atraumatic UV gel nail removal. It is critical to allow enough time for the solvent to break the adhesive bonds to the natural nail so that excessive force in removing the nail is avoided. Manufacturers often recommend specific time for soaking the nail in acetone. It is important to note that this is often a minimum time and may be inadequate. Soaking timing depends on the thickness of the nail, its composition and the degree of cure, and a longer soaking time may facilitate less trauma duRing removal in the emergency department (ED) or clinic. Forceful scraping or prying techniques may damage the natural plate resulting in a pitting appearance. Such aggressive tech- niques for removal may also result in further trauma in cases of under- lying fracture or soft tissue injuries.

Unless specifically instructed by the nail manufacturer, it is generally not recommended to use an abrasive file to thin the nail [7]. If an abra- sive file is used, the UV gel nail should not be filed full thickness and aggressive filing should be avoided to prevent further trauma to the intact or injured tissue.

According to the Nailpro organization, the removal of acrylic nails should follow the same basic principles as the removal of UV gel nails [8]. As with gel nails, acrylic nails should never be pried or forced off as this could result in damage to the underlying nail plate [8]. Before the nail is soaked in the acetone-based nail removal solution, the acrylic nail should be shortened, and the lacquer or gel nail polish should be removed. The acrylic nail can be submerged, or alterna- tively, gauze or cotton balls soaked with acetone may be applied directly to the nail. Once the acrylic nail has been adequately soaked, the softened nail can be pushed off of the natural nail plate with an object that has an edge such as a tongue depressor with care to avoid prying or forceful removal.

A 23-year-old left hand-dominant woman presented to a level 1 trauma center with chief complaint of left thumb pain after trip and fall onto her left hand. On examination in the ED, the patient was found to have artificial nails and tenderness to palpation of the thumb (Fig. 1A and B). Radiographs revealed a left thumb distal phalanx frac- ture (Fig. 2A-C). The patient was placed in a splint, discharged, and re- ferred for further evaluation in orthopedic hand clinic. The artificial nail was never removed, and the patient was not evaluated for subungual hematoma in the ED. The patient was seen in clinic 1 week after the index injury. The patient removed the artificial nail using ace- tone, and upon direCT examination of the nail plate with the artificial nail removed, no subungual hematoma was observed (Fig. 3). Ultimate- ly, this patient did well and avoided any complications; however, lack of adequate examination upon initial visit including artificial nail removal could have resulted in a missed injury such as subungual hematoma or nail bed laceration.

Complete examination of all traumatic finger tip injuries includes assessment of both the nail plate and nailbed [6]. Artificial nails, includ- ing UV gel and acrylic nails, may mask nail plate and nail bed injuries if these are not removed by providers during initial physical examination. Simon and Wolgin [1] found that 60% of patients who had a subungual hematoma of 50% or greater had a nail bed laceration that required

336 Correspondence/ American Journal of Emergency Medicine 34 (2016) 307–337

Fig. 1. On examination in the ED, the patient was found to have acrylic nails and tenderness to palpation of the thumb.

Fig. 2. Anteroposterior, oblique, and lateral radiographs of left thumb demonstrated a transverse distal phalanx fracture.

repair. They found that incidence of nail bed laceration is greater than 95% if there is a fracture associated with the subungual hematoma [1]. Nail bed lacerations that are missed or left unrepaired may result in scarring and permanent deformity to the regenerating nail [1].

The classic teaching that subungual hematomas greater than 50% of the area of the nail should prompt nail removal for examination of the

Fig. 3. The acrylic nail was removed using an acetone-based nail remover, and upon direct examination of the nail plate with the acrylic nail removed, no subungual hematoma was observed.

nail bed has not been universally accepted [1]. Roser and Gellman [9] demonstrated that nail bed repair and nail trephination of subungual hematoma greater than 25% of the nail have equivalent outcomes and no greater complications in children. Seaberg et al [10] similarly demon- strated that trephination of subungual hematomas in adults results in no complications or nail deformities. Similarly, a systematic review in 2012 found that outcomes as defined by nail cosmesis were ultimately unaffected by treatment choice [11].

Regardless of nail bed repair or nail trephination, it is critical to eval- uate the nail plate for subungual hematoma and nail bed injuries to make the Initial diagnosis. In the case presented, the patient was at a high risk for developing a subungual hematoma given a force sufficient to fracture the distal phalanx and her presentation to the ED with severe pain. In addition, it would have been prudent to remove the artificial nail as these have been shown to harbor pathogens and that could be a source of infection in the setting of a nail bed laceration (Fig. 4) [2-4]. Given the paucity of peer-reviewed literature regarding artificial nail Removal techniques and unclear recommendations regarding the use of acetone-based nail removers in the setting of open wounds, we recommend that the artificial nail removal guidelines we report should be used for finger tip injuries that are not associated with gross wounds or lacerations.

Traumatic fingertip injuries are exceedingly common and often times very easy to diagnose based on mechanism and visual inspection. The presence of artificial nails, however, can mask the presentation of an underlying nail bed injury. We recommend that the artificial nail removal guidelines we report should be used for finger tip injuries that are not associated with gross wounds or lacerations.

Correspondence/ American Journal of Emergency Medicine 34 (2016) 307–337 337

Fig. 4. This is an example of another patient who presenting with concern for infection. The acrylic nail was removed revealing gross purulence draining from a defect in the native nail plate.

Joseph A. Gil, MD? Steven DeFroda, MD Daniel Reid, MD

P. Kaveh Mansuripur, MD

Department of Orthopaedic Surgery, Warren Alpert School of Medicine

Brown University, Providence, RI

?Corresponding author at: Department of Orthopaedic Surgery Warren Alpert Medical School, Brown University, 593 Eddy Street Providence, RI 02903. Tel.: +1 773 551 4083; fax: +1 401 444 6182

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.11.014

References

1. Simon RR, Wolgin M. Subungual hematoma: association with occult laceration re- quiring repair. Am J Emerg Med 1987;5(4):302-4 [http://www.ncbi.nlm.nih.gov/ pubmed/3593496. Accessed September 8, 2015].
2. Pottinger J, Burns S, Manske C. Bacterial carriage by artificial versus natural nails. Am J Infect Control 1989;17(6):340-4.
3. McNeil SA, Foster CL, Hedderwick SA, Kauffman CA. Effect of hand cleansing with an- timicrobial soap or alcohol-based gel on microbial colonization of artificial finger- nails worn by health care workers. Clin Infect Dis 2001;32(3):367-72.
4. Rubin DM. Prosthetic fingernails in the OR. A research study. AORN J 1988;47(4): 944-5 [948].
5. Zook EG. Anatomy and physiology of the perionychium. Hand Clin 2002;18(4): 553-9 [v].
6. Patel L. Management of simple nail bed lacerations and subungual hematomas in the emergency department. Pediatr Emerg Care 2014;30(10):742-5 [quiz 746-748. http://www.ncbi.nlm.nih.gov/pubmed/25275357. Accessed October 18, 2015].
7. Removal of UV Gel Manicure Coatings. http://files.nailsmag.com/Handouts/ RemovingUVGels.pdf. [Accessed October 20, 2015].
8. Technique: How to Remove Acrylics | Nailpro. http://www.nailpro. com/technique- how-to-remove-acrylics. [Accessed October 20, 2015].
9. Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg [Am] 1999;24(6):1166-70 [http://www.ncbi.nlm.nih.gov/pubmed/10584937. Accessed September 8, 2015].
10. 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 [http://www.ncbi.nlm.nih.gov/pubmed/2018587. Accessed September 8, 2015].
11. Dean B, Becker G, Little C. The management of the acute traumatic subungual haematoma: a systematic review. Hand Surg 2012;17(1):151-4 [http://www.ncbi. nlm.nih.gov/pubmed/22351556. Accessed October 20, 2015].