Salvaging a Totally Avulsed Nail Bed Using Free Grafting and Postoperative Ice Cooling: A Case Report

Peer Reviewed

Case Report

Salvaging a Totally Avulsed Nail Bed Using Free Grafting and Postoperative Ice Cooling: A Case Report

Keywords

April 2021

ISSN 1943-2704

Index Wounds 2021;33(4):E28-E30.

Abstract

Most nail bed injuries occur along with other fingertip injuries; however, isolated total avulsion injuries of the nail bed are uncommon. To obtain optimal results, reconstructive methods should be selected judiciously depending on the type of injury, the patient’s needs for their economic status and postoperative aesthetics, and postoperative morbidities. Replantation with an avulsed nail bed, if feasible, can be a reasonable treatment option to avoid the morbidities of other donor sites. This report presents a rare case of a 26-year-old man who experienced an isolated total avulsion injury of the nail bed with exposure of the phalangeal bone while using machinery, which was treated successfully with free grafting and postoperative ice cooling.

Introduction

Nail bed injuries often are associated with fingertip injuries and pose a surgical challenge because inadequate management can result in irregular and nonadherent nail deformities. Depending on the type of injury, various treatment modalities can be considered. Traditionally, nail bed defect treatment is size-dependent, and management may involve healing by secondary intention or nail bed grafting. For avulsion injuries of the nail bed, a split-thickness graft harvested from an uninjured portion of the involved finger¹ or a greater^2,3 or lesser toe⁴ has been preferred over other repair methods to avoid nail deformities and ensure natural nail growth. However, studies have reported that nail bed grafting is not necessary due to the regenerative potential of the nail bed.^5,6 The nail bed obtained from an amputated part also can be used as donor tissue to repair nail bed defects. When the avulsed nail bed is in suitable condition for grafting with adequate preservation, replantation should be considered first to avoid morbidities of other donor sites.

Case Report

A 26-year-old male injured the left fourth digit while using machinery. The patient presented to the emergency room with the amputated portion, which included the complete nail bed attached to a small area of the dorsal skin and an exposed distal phalanx with the periosteum denuded (Figure 1A). The amputated portion with the nail removed was divided into 2 parts—the nail bed and skin. Each was replanted in its original place as a free graft, and the patient was provided a digital nerve block (Figure 1B). The nail that had been separated from the amputated portion was kept in place for postoperative support. The surgical wound was lightly dressed using Mepilex Lite (Mölnlycke Health Care AB) and wrapped with a finger cot. The patient was discharged and instructed to keep the grafted nail bed cool by using vinyl bags filled with crushed ice continuously for 7 days, while taking care not to keep it too cold in order to avoid frostbite.

The patient returned to the outpatient clinic the next day for the surgical wound to be checked; thereafter, the patient was evaluated every other day for 2 weeks. Both the grafted nail bed and skin survived successfully, with no noteworthy events such as graft loss or infection, during a 4-week follow-up period (Figure 2A). The patient was instructed to frequently apply a moisturizing cream on the grafted area so that it did not dry out; this was continued beyond initial follow-up.

A 2-year postoperative examination showed natural nail growth and excellent fingertip appearance (Figure 2B). The patient did not experience any adverse events.

Discussion

The fingernail is a specialized skin appendage that is essential to the appearance and function of the fingertip. Nail bed tissue is involved in shaping and attaching the advancing nail. Nail bed defects are repaired using the same tissue because the replacement of the nail bed by another tissue (eg, skin or dermis) rarely facilitates adherence of the nail.⁴

Regardless of the donor tissue, the recipient site should be well-vascularized to support survival of the grafted tissue. Bone denuded of the periosteum is unsuitable for grafting because of its avascularity. Several authors^2,3 have reported that preparation of the injured area is necessary for graft survival in such circumstances; Matsuba and Spear²decorticated the distal phalanx to induce granulation tissue growth and Yang et al³ used a vascularized fascial flap on the bare bone before grafting. Such preconditioning procedures are helpful to enhance graft survival on an avascular bed but are not without associated postoperative morbidities.

Postoperative cooling can be an alternative to preconditioning for salvaging a nail bed grafted to bare bone. As the distal phalanx devoid of periosteum is poorly vascularized, a nail bed grafted to bare bone heals by revascularization from the wound margin via a bridging phenomenon, whereby grafts on avascular beds are revascularized.⁷ In order to survive, a graft on an avascular bed must overcome poor vascular conditions until revascularization occurs from the margin. Cooling can facilitate graft survival by reducing the metabolic demands of the graft, thereby slowing its cellular degeneration and preventing irreversible damage.⁸ Therefore, the present authors suggest that postoperative cooling played a critical role in enhancing the survival of the nail bed grafted to bare bone in this case.

However, to the authors’ knowledge, no guidelines regarding the optimum temperature and duration of cooling are available. Two mechanisms of graft revascularization on the vascular bed have been described: inosculation and neovascularization. Inosculation occurs 2 to 5 days after grafting, followed by capillary budding, which normally develops after 5 days.⁹ Considering that an avascular bed requires more time for neovascularization than a vascular bed, the present authors suggest that postoperative cooling should be performed for more than 5 days to enhance graft survival on an avascular bed. As such, it is recommended that continuous ice cooling be performed for 7 days.

Cooling might cause some degree of vasoconstriction at the recipient site, but without a critical effect on graft survival.¹⁰However, care should be taken not to make the tissue too cold or keep it cool for too long to prevent undesirable effects such as frostbite and poor revascularization.¹¹ In the present case, no drugs were prescribed to prevent vasoconstriction caused by cooling; however, lipo-prostaglandin E1, which is used as a vasodilator in the treatment of peripheral vascular diseases, may be considered for such purposes.¹⁰ Further research is required to determine the proper temperature and duration of postoperative cooling to enhance graft survival on an avascular bed and to develop a monitoring tool to maintain the optimal temperature.

Limitations

Only one case was analyzed in the present study. Additional studies including more cases are needed to assess the outcomes of postoperative cooling on the survival rate of grafted nail bed on the avascular distal phalanx. Additionally, there were some limitations in managing the patient’s wound because there were no monitoring tools available to maintain optimum temperature. Further research is required to develop such devices.

Conclusions

A nail bed totally avulsed from the distal phalanx was successfully salvaged using a free graft and postoperative cooling to improve graft survival. With further refinements, this technique may be promising for the treatment of such injuries.

Authors: Kun-Yong Sung, MD¹; and Sang-Yeul Lee, MD²

Affiliations: ¹Department of Plastic and Reconstructive Surgery, School of Medicine, Kangwon National University, Chuncheon, Korea; ²Department of Plastic and Reconstructive Surgery, Kangwon National University Hospital, Chuncheon, Korea

Correspondence: Sang-Yeul Lee, MD, Department of Plastic & Reconstructive Surgery, Kangwon National University Hospital, Baekryeong-ro 156, Chuncheon 24289, Korea; serafin5@unitel.co.kr

Disclosure: The authors disclose no financial or other conflicts of interest.

References

1. Shepard GH. Treatment of nail bed avulsions with split-thickness nail bed grafts. J Hand Surg Am. 1983;8(1):49–54. doi:10.1016/s0363-5023(83)80052-5.

2. Matsuba HM, Spear SL. Delayed primary reconstruction of subtotal nail bed loss using a split-thickness nail bed graft on decorticated bone. Plast Reconstr Surg. 1988;81(3):440–443. doi:10.1097/00006534-198803000-00023

3. Yang J, Wang T, Yu C, Gu Y, Jia X. Reconstruction of large area defect of the nail bed by cross finger fascial flap combined with split-thickness toe nail bed graft: a new surgical method. Medicine (Baltimore). 2017;96(6):e6048. doi:10.1097/MD.0000000000006048

4. Saito H, Suzuki Y, Fujino K, Tajima T. Free nail bed graft for treatment of nail bed injuries of the hand. J Hand Surg Am. 1983;8(2):171–178. doi:10.1016/s0363-5023(83)80010-0

5. Ogo K. Does the nail bed really regenerate? Plast Reconstr Surg. 1987;80(3):445–447. doi:10.1097/00006534-198709000-00020

6. Ogunro O, Ogunro S. Avulsion injuries of the nail bed do not need nail bed graft. Tech Hand Up Extrem Surg. 2007;11(2):135–138. doi:10.1097/BTH.0b013e318030a566

7. van Wingerden JJ, Lapid O, van der Horst CM. Bridging phenomenon—simplifying complex ear reconstructions. Head Neck. 2014;36(5):735–738. doi:10.1002/hed.23458

8. Hirasé Y. Postoperative cooling enhances composite graft survival in nasal-alar and fingertip reconstruction. Br J Plast Surg. 1993;46(8):707–711. doi:10.1016/0007-1226(93)90204-o

9. Conway H, Stark RB, Joslin D. Observations on the development of circulation in skin grafts. II. The physiologic pattern of early circulation in auto-grafts. Plast Reconstr Surg. 1951;8(4):312–319. doi:10.1097/00006534-195110000-00014

10. Eo S, Hur G, Cho S, Azari KK. Successful composite graft for fingertip amputations using ice-cooling and lipo-prostaglandin E1. J Plast Reconstr Aesthet Surg. 2009;62(6):764–770. doi:10.1016/j.bjps.2007.09.064

11. Hirasé Y. Free composite graft to claw nail deformity using the ice water cooling method. Tech Hand Up Extrem Surg. 1998;2(1):47–49. doi:10.1097/00130911-199803000-00006

1. Shepard GH. Treatment of nail bed avulsions with split-thickness nail bed grafts. J Hand Surg Am. 1983;8(1):49–54. doi:10.1016/s0363-5023(83)80052-5.

4. Saito H, Suzuki Y, Fujino K, Tajima T. Free nail bed graft for treatment of nail bed injuries of the hand. J Hand Surg Am. 1983;8(2):171–178. doi:10.1016/s0363-5023(83)80010-0

5. Ogo K. Does the nail bed really regenerate? Plast Reconstr Surg. 1987;80(3):445–447. doi:10.1097/00006534-198709000-00020

6. Ogunro O, Ogunro S. Avulsion injuries of the nail bed do not need nail bed graft. Tech Hand Up Extrem Surg. 2007;11(2):135–138. doi:10.1097/BTH.0b013e318030a566

7. van Wingerden JJ, Lapid O, van der Horst CM. Bridging phenomenon—simplifying complex ear reconstructions. Head Neck. 2014;36(5):735–738. doi:10.1002/hed.23458

8. Hirasé Y. Postoperative cooling enhances composite graft survival in nasal-alar and fingertip reconstruction. Br J Plast Surg. 1993;46(8):707–711. doi:10.1016/0007-1226(93)90204-o

11. Hirasé Y. Free composite graft to claw nail deformity using the ice water cooling method. Tech Hand Up Extrem Surg. 1998;2(1):47–49. doi:10.1097/00130911-199803000-00006