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Case report
Acellular dermal matrix reconstruction of a nail bed avulsion in a 13-year-old child
  1. Ailbhe L Kiely1,2,
  2. Lilli RL Cooper2 and
  3. Aina Greig2
  1. 1Department of Plastic and Reconstructive Surgery, Queen Elizabeth Hospital, Birmingham, UK
  2. 2Department of Plastic and Reconstructive Surgery, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
  1. Correspondence to Ailbhe L Kiely; ailbhe.kiely{at}nhs.net

Abstract

Nail bed avulsion injuries often require reconstruction, particularly in cases where the avulsed fragment is lost. We describe a simple way to reconstruct a large nail bed defect, with no donor site. A 13-year-old boy with a hypoplastic left heart and autism accidentally sustained a left little distal phalanx injury with an avulsion of 60% of the nail bed, exposing the distal phalanx. This boy had a history of poor compliance, qualifying the need to find a technique that would minimise operative time and dressing changes. As such, it was elected to use an acellular dermal matrix (ADM) (Matriderm) as a one-step reconstruction. Signs of vascularisation of the ADM were noted at 2 weeks, and 3-month follow-up demonstrated integration, with normal nail growth. We found that Matriderm was able to support the regeneration of a full thickness wound in a simple one-step procedure.

  • orthopaedic and trauma surgery
  • plastic and reconstructive surgery
  • paediatric surgery
  • trauma

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Background

Fingertip injuries make up two-thirds of injuries to the hand in children. Of these, nail bed damage occurs in 15%–24%.1 The majority are simple and can be closed directly; however, those with a nail bed avulsion defect are more difficult to address. Where the avulsed segment is unavailable, options include shortening the finger, managing the defect conservatively or reconstructing it.2 Depending on the size of the defect, reconstructive options can be time-consuming and involve a second donor site. Acellular dermal matrices are acellular tissues, generated from human, porcine or bovine samples by decellularisation, preserving the extracellular dermal matrix as a scaffold on which donor cells or surrounding native tissue can grow. They are being increasingly used across many areas of plastic surgery, from burn reconstruction3 to cancer reconstruction4 and occasionally in trauma where there is exposed tendon or bone. We describe a simple, quick and easy way to reconstruct a large nail bed defect, with no donor site, using materials readily available in most plastic surgery units. To the authors’ knowledge, the use of ADM alone has never been described for the reconstruction of a nail bed avulsion.

Case presentation

Patient history, diagnosis and patient selection

A 13-year-old boy with a hypoplastic left heart requiring multiple operations as a baby and autism accidentally sustained a left little fingertip injury in the hinge of a door. He avulsed the majority of the nail bed (60% of the sterile matrix), exposing the underlying distal phalanx, which had a tuft fracture (figure 1). There was insufficient residual nail bed to provide a nail bed graft and the avulsed portion was not available. He had a history of poor compliance with dressing changes and disliked hospital visits. He presented to our unit with appropriate tetanus and antibiotic cover for surgical management of the injury.

Figure 1

Nail bed avulsion left little finger with approximately 60% triangular shaped defect exposing distal phalanx.

Treatment

Operative methods

Step 1: the avulsion defect was explored, irrigated and measured. The triangular defect had relatively straight 5 mm borders with roughly 60° angles. It represented approximately 60% of the sterile matrix.

Step 2: a template of the defect was marked out on cardboard for measurement of the ADM.

Step 3: a double layer of 1 mm thickness Matriderm (MedSkin Solution Dr. Suwelack AG, Billerbeck, Germany) was cut to match the template.

Step 4: the Matriderm was checked against the nail bed defect (figure 2).

Figure 2

Measurement of defect for placement of acellular dermal matrix.

Step 5: the Matriderm was secured with continuous 6/0 Vicryl Rapide (Ethicon) (figure 3).

Figure 3

Matriderm sutured to nail bed defect.

Outcome and follow-up

The patient was followed up at 2 weeks, 6 weeks, 3 months and 9 months . At 2 weeks, the ADM appeared integrated and vascularised. At 6-week follow-up, the nail showed early signs of regrowth. Finally, at 3-month follow-up, the nail plate had regrown, with no evidence of deformity, as shown in figure 4. Due to biting his nails, the nail plate has remained relatively short at 9-month follow-up.

Figure 4

Complete nail plate regrowth at 3-month follow-up, with desirable cosmetic outcome.

Discussion

An avulsed nail bed is a relatively rare nail bed injury for which various reconstructive options exist, depending on the patient’s preference. Some adults prefer the finger to be shortened for a speedy recovery. However, in most paediatric cases, maintaining finger length is favoured.1 For a child with significant cardiac risk, a short, single operative time is preferable. Behavioural problems as such demonstrated by our patient necessitate consideration of the fewest wounds to dress, the fewest dressing changes/hospital visits and minimised associated discomfort. Finally, in the current economic climate, the cost of the intervention must be considered.

The majority of published reconstructive techniques for a lost, avulsed nail bed involve a secondary, donor site. Techniques include nail bed grafts from other fingers or toes (with associated donor site morbidity), adipofascial turnover flaps with skin grafts, other rotational flaps or ADM with fat grafting.2 5 6 These also may incur a significant increase in operative time, depending on the complexity of the option. The use of an ADM in this context has not been described.

ADMs offer a biocompatible alternative to autologous tissue. When implanted to a human host, it forms the framework upon which donor cells or surrounding native tissue can grow while decreasing the risk of infection or extrusion by its acellularity. Matriderm is a bovine ADM, made up of collagen derived from dermis coupled with elastin from the nuchal ligament.7

The use of an ADM in isolation (in this case, Matriderm) has never previously been described for nail bed reconstruction. In addition to wide availability and ease of application, they may improve comfort for dressing changes and reduce the number of appointments required.8

The drawback of ADM use is their cost. In this instance, the cost of the Matriderm was £265 for a 52×74×1 mm piece.9 This said, we know that theatre time costs £60 per minute or £1200 per hour.10 It is therefore likely that this offered a cost-neutral or cost-advantageous option compared with an alternative with a longer procedure time. It may also have required fewer dressing clinic follow ups, and less dressing material in the follow-up period, suggested by reported accelerated wound healing when using ADM in combination with grafting versus graft alone.8

Patient’s perspective

Patient’s mother: We are quite happy with the process. The outcome was better than what we thought. He has nail growth back and it looks normal. We are quite pleased overall.

Learning points

In comorbid paediatric cases such as ours, where finger length preservation and a short operative time is important, our solution of acellular dermal matrix (ADM) alone is very persuasive:

  • We found that Matriderm was able to support the regeneration of a full thickness wound in a one-step procedure, especially advantageous in minimising further procedures in this boy with an extensive cardiac history.

  • Its use as a biological dressing potentially reduced the pain of dressing changes, as well as their frequency, of relevance to his diagnosis of autism.

  • We describe a simple, quick and easy way to reconstruct a large nail bed defect, with no donor site, using materials readily available in most plastic surgery units.

References

Footnotes

  • Contributors AK: assisted with operation and wrote manuscript. LRLC: performed operation, contributed to manuscript and organised follow up. AG: recruited patient, supervised operation, suggested the intervention, followed up patient and approved manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Parental/guardian consent obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.