The Procedural Pause

Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, PNP, are teaming up to create a new EMN blog, The Procedural Pause.

The blog will focus on procedures that emergency medicine residents and midlevel providers are often called on to perform in the ED. Each case will cover the basics, the best approach for treatment, and pearls and pitfalls.

The Procedural Pause publishes anonymous case studies that required an ED procedure. The site welcomes all providers to share their ideas about emergency medicine, procedures, and experience with similar cases. Application of the information in this blog remains the professional responsibility of the practitioner.

Like all texts, manuals, support guides, and blogs, this site conveys personal opinions and experiences. Providers may approach a patient or procedure in many ways, and this blog is not a dictum nor is it meant to dictate standard of care. It is a clinical guide, not a legal document; do not reference this site in court or as a defense. It is your responsibility to follow your hospital’s procedures and protocol and to practice under the guidelines of your professional license.

Tuesday, January 3, 2017

Pediatric Nail Bed Laceration Basics – Part 5

​When and where should you use prolene? What about nylon suture threads? We will end with the latest on antibiotic use in hand injuries.

Pediatric nail bed laceration and finger laceration. Tissue adhesives can be used in place of absorbable sutures for minor injuries to the nail bed.

Nylon vs. Prolene

How do we decide on which to use and where to use it? Prolene is a synthetic, monofilament, non-absorbable polypropylene thread. This material can be difficult to handle, and many practitioners avoid using it. Its fishing thread-like structure makes it stiff, and its knots tend to be loose, especially for larger threads.

Nylon is the go-to non-absorbable material we use for a plethora of superficial wounds because it is extremely easy to use. It is a silkier material that can come in various forms and thickness. Prolene may be a better choice for wound repair if you want to lessen the patient's pain and make your colleague's job easier, such as for eyebrow lacerations. This way, when the provider removes the sutures, the thread won't blend in like the nylon ones (making it hard to find). Don't use prolene anywhere else on the face because cosmetic healing can be compromised if the knots slip or move.

Where else can we use prolene? Have you ever tried to suture the scalp with prolene? We suggest giving it a whirl. Hand tying the knots (with surgeon knots) is easy and makes for a strong knot if it is too difficult to tighten them with your tools. Staples can be used in the scalp with ease, but sutures are less painful to remove and just as efficient. Often prolene is a good choice for bald patients. Staples can leave larger scars and prolene may allow for enhanced cosmetic results while still being extremely durable.

Prolene isn't always the first choice in terms of non-absorbable suture and can be more expensive than nylon. Some other disadvantages of prolene include brittleness, plastic-like feel, and being more difficult to use than nylon. Prolene, however, has its uses for eyebrow lacerations, scalp lacerations, and larger wounds. There is minimal tissue reactivity and durability when compared with nylon.

Nylon is the better choice as far as any finger laceration repair is concerned. The nail bed, however, should be handled differently. Finger lacerations can typically be repaired with 5.0 or 4.0 nylon sutures. Repair of small nail bed lacerations with absorbable sutures (unless partially amputated or brutally severed) is not indicated.

If the nail bed laceration is minor (or even moderate) and you can easily replace the nail over the wound, then do not suture the nail bed. Studies indicate nails can be tacked back down with tissue adhesives and heal in the same fashion with no difference in wound infection rates or complications as if sutures had been used. This practice has been in place for decades although many practitioners are still using sutures in the nail bed. (Plast Reconstr Surg 1999;103[7]:1983). Sutures in the nail bed can also increase infection rates and prolong recovery.

Dermabond, a type of tissue adhesive otherwise known as 2-octylcyanoacrylate.

A 2008 study from the University of Washington published in The Journal of Hand Surgery drew the same conclusions. (2008;33[2]:250.) Nail bed repair performed with Dermabond is "significantly faster than suture repair, and it provides similar cosmetic and functional results," and it is suggested in "the management of acute nail bed lacerations [as an] efficient and effective repair technique." Stop tediously sewing nail bed lacerations with a thin thread that only breaks and makes everyone's life more difficult. Consider tissue adhesive next time you see this injury.

Note the laceration on the side of the finger should be repaired with a 4.0 or 5.0 nylon suture thread. The minor lacerations under the nail can be covered with tissue adhesive, and the nail can be placed directly back onto the bed.

What about Infection Rates and Antibiotics?

Literature comparing wound healing rates of nylon and prolene threads is sparse. A 2003 study in The Journal of Oral Diseases assessed four different suture materials (catgut, silk, polypropylene, and Vicryl) in the soft tissues of 32 Sprague Dawley rats. (2003;9[6]:284.) The results demonstrated that Vicryl produced the mildest tissue reaction during early healing. It is well-known that absorbable sutures (like Vicryl) can be used on the face and reinforced with tissue adhesives and have similar healing rates as non-absorbable threads.

We highly recommend using Vicryl for facial wounds. "No difference in long-term cosmetic results of repairs with permanent or absorbable suture material" was seen in adults with clean wounds of the face or neck. (Arch Facial Plast Surg 2003;5[6]:488.) Many providers may agree they prefer absorbable sutures because they do not have to be removed, saving time and lessening the patient's anxiety and pain.

Vicryl can be used for many superficial and partial thickness wounds on the face. Patients do not have to follow up for suture removal because they are absorbable. Tension strength lasts up to seven days.

When are antibiotics indicated for hand injuries for infections? The bottom line is the hand does not like foreign materials. Hand injuries tend to get infected more often than other sites on the body because they are well-exposed, they have multiple areas of flexion and extension, and they have very little subcutaneous fat and overall space. ED providers should be wary of placing deep sutures in the hand in general. We suggest all tendon repairs be followed up with a hand specialist, and you will stay out of trouble deep down in the hand.

Normal, healthy children and adults do not need prophylactic antibiotics. You may have been taught that open fractures in the hand always need prophylactic antibiotics. A recent 2016 study published in The Journal of Hand Surgery completed a systematic review to determine whether prophylactic antibiotics reduce the risk of superficial infection and osteomyelitis following open distal phalanx fractures. (2016;41[4]:423.) A meta-analysis of four randomized controlled trials (353 fractures) were examined. There was no statistically significant difference between rates of superficial infection in the two groups.

These results fail to show any effect of prophylactic antibiotics on the rate of superficial infections following open distal phalanx fractures, and the authors suggested that treatment should focus on prompt irrigation and debridement rather than administration of prophylactic antibiotics.

If you still have doubts and your patient is immunocompromised or high-risk, IV Ancef or Cefazolin over 15 minutes prior to discharge (along with tetanus update) may be considered. Then, Keflex for five to seven days may be a useful adjunct. Clindamycin could be used as an alternative for patients with allergies. Prophylactic anything, however, may not make a darn bit of difference.

Watch Ms. Roberts repair a nail bed laceration in this video.​