nailbed lac

[basementbeast]

any good techniques to speed up nailbed laceration repairs....i did digital block, removal of nail, trephenation, suture through trephenation holes to close lac and reattach nail....all in all took waaaay to long.....i had to get up several times to go give benzo's to a seizure, talk to a consultant, etc...

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[NKMU]

Consult Hand. 😉

 

[Dr.Evil1]

A flexor tendon sheath block can sometimes be a good thing especially on the index and pinkey finger. It takes less time to get numb and is more reliable in my experience on those two fingers.

All suturing takes time, especially if you like to do a good job. Long acting anesthetics are your friend so you can get up and do other things if necessary.

 

[Mary Jane Watson]

I did a nail bed lac repair the other day. The flexor tendon sheath block was awesome. I used 1/2 marcaine and 1/2 lido for the mix. It's nice to give your patients the extended anesthesia, plus it gives you plenty of time if you get pulled away.

 

[basementbeast]

i don't have hand where i work....just general ortho....i used bupivicaine...

 

[BADMD]

any good techniques to speed up nailbed laceration repairs....i did digital block, removal of nail, trephenation, suture through trephenation holes to close lac and reattach nail....all in all took waaaay to long.....i had to get up several times to go give benzo's to a seizure, talk to a consultant, etc...

I looked at the literature a few years ago about nail bed lacs. The conclusion I came to was that most nail bed lacs didn't actually need repair (I wish I had kept the references). If the nail is intact, it splints the wound edges. You are very likely to cause as much injury removing the nail and fixing the wound as you are to just leaving it alone.

For the crush injury to the finger I usually just trephonate if the subungal hematoma is >25% or symptomatic. I've seen stuff about lifting nails to look for occult lacs, but the outcomes between operative and simple trephonation are the same. Any deformities in the nail grow out.

 

[basementbeast]

the nail was fractured, you could see the nailbed lac, there was a phalangeal fracture under that...

 

[DrQuinn]

I had a real bad nail injury, including near unroofing of nail, tuft's fracture, etc. I sat there, and talked to the guy, nearly called ortho (who does hand coverage). I ended up not doing it, splinting his finger/xerofoam/pain meds, refer to ortho as outpatient.

I lost a lot of sleep that night... and ended up doing some research, and over the next week or two talk to two hand surgeons and several orthopedic residents... the consensus was in there is no consensus in treating nailbed lacerations anymore, and a lot of times they will heal on their own, with maybe some nail deformity.

Sure as hell made me feel a lot better...
Q

 

[EM2BE]

If you do the whole nail removal, use the extended anesthesia. Removed nails are extremely painful and the longer they are numb, the better. I wish there was a way to numb it for a few days. (speaking from personal experience)

 

[Seaglass]

Time Saver: Do nothing. Your patient will thank you.

 

[macdaddy23]

If you do have to repair it one of the lecturers at ACEP doesn't suture the nailbed they dermabond it then sew the nail back on top(if it's there).

I agree with him in that it sometimes is not easy to sew through that tissue especially a crush injury.
So I am going to start dermabonding those.

 

[spyderdoc]

I like to use Dermabond, but you have to be careful to not let it run into the nail ffolds, otherwise you wont be able to get the nail back into place. You may want to but some abx ointment around the nail folds with a Qtip just to prevent the Dermabond from getting in....

 

[basementbeast]

two alternatives:
1) do nothing....so what (if anything) happens to the unrepaired lac..??
2) dermabond the lac ... then glue the nail on???

 

[dowiattp]

For nailbed lacs, I just do a volar digital block (1:1 .5% marcaine/2% lido), remove the nail, and bury 5-0 vicryl sutures in the lac. No need to reattach the nail- just keep it covered and clean for 10-14 days. I also like to bring people back for a wound check after a day or two.

 

[spyderdoc]

For nailbed lacs, I just do a volar digital block (1:1 .5% marcaine/2% lido), remove the nail, and bury 5-0 vicryl sutures in the lac. No need to reattach the nail- just keep it covered and clean for 10-14 days. I also like to bring people back for a wound check after a day or two.

I hate these "return for wound check" visits for no good reason. It clutters up the waiting room and wastes the guy's (and my) time. I tell the person to come back if there are concerns or signs/sx of infection. Otherwise wait until it is time to have the sutures removed....

Sometimes I will do a follow up phone call to check up on someone that I am concerned about..the pateints generally appreciate this...

 

[dowiattp]

I hate these "return for wound check" visits for no good reason. It clutters up the waiting room and wastes the guy's (and my) time. I tell the person to come back if there are concerns or signs/sx of infection. Otherwise wait until it is time to have the sutures removed....

Sometimes I will do a follow up phone call to check up on someone that I am concerned about..the pateints generally appreciate this...

I'm very clear with patients that wound checks are only done between 6 and 9am, when it is least busy, and only on the urgent care side. I tell them they're welcome to come any other time, but not to be surprised if they wait 2 or 3 hours to see a provider for 5 minutes and then wait another half hour to be discharged.

There are a fair number of people with occupational related injuries (lawncare people putting hands in lawnmowers, restaurant workers with fingers in cheese slicers, etc.), so I think a wound check reinforces the need to keep the wound clean/dry and also to avoid using the arm/hand/etc. if it shouldn't be.

I agree though, when they roll in at 5pm on a Monday.... not so fun.

 

[Seaglass]

I'm very clear with patients that wound checks are only done between 6 and 9am, when it is least busy, and only on the urgent care side. I tell them they're welcome to come any other time, but not to be surprised if they wait 2 or 3 hours to see a provider for 5 minutes and then wait another half hour to be discharged.

There are a fair number of people with occupational related injuries (lawncare people putting hands in lawnmowers, restaurant workers with fingers in cheese slicers, etc.), so I think a wound check reinforces the need to keep the wound clean/dry and also to avoid using the arm/hand/etc. if it shouldn't be.

I agree though, when they roll in at 5pm on a Monday.... not so fun.

Yeah the problem is that they DO come in at the wrong time and take up a bed for an hour for no good reason. I don't do rechecks - I tell them to come back if it's not improving in 4 days (for abscesses or cellulitis) or if it's worsening after 2 days (need 2 days for ABX to do anything). If I'm worried about something I call.

 

[southerndoc]

Can we bill for a follow-up phone call? (This is a serious question.)

 

[dowiattp]

Yeah the problem is that they DO come in at the wrong time and take up a bed for an hour for no good reason. I don't do rechecks - I tell them to come back if it's not improving in 4 days (for abscesses or cellulitis) or if it's worsening after 2 days (need 2 days for ABX to do anything). If I'm worried about something I call.

You let them have a bed? 😉

Granted every place is different; where I was last month, people got a chair if they were lucky. Usually they'd be in the waiting room until someone was immediately ready to look at their wound.

As far as I know, you can't bill for anything within 10 days of the procedure, as it is covered in the general surgical fee or whatever it is called (don't remember, sorry).

 

[docB]

Can we bill for a follow-up phone call? (This is a serious question.)

I don't think so. It would likely be seen as falling under the billing for the initial visit. It might raise the complexity and could possible raise the level for the visit but you'd have to have the chart open until you made the call. We close the chart and scan it to billing at the end of each visit. To add in the call note and have it count for billing you'd have to keep the chart open and not give it to billing until after you made the call and documented it. I can't see it being worthwhile.

Of note, a follow up wound check is not billable. It's considered part of the initial wound care. Having them follow up in the ED costs you money because they take up space and you don't charge them. I refer to PMD unless I'm particularly concerned.

 

[Jeff698]

Speaking of billing and nails, I trimmed an ingrown toenail the other day after a digital block. While I was doing it, something in the back of my head was telling me this reimbursed fairly well. I then sat down to document it and wondered what the key components were for full billing.

Of course, it may reimburse poorly and I may be confusing it with disimpaction. A technically un-challenging procedure that I'm pretty sure reimburses well.

Take care,
Jeff

 

[kungfufishing]

great returns there, up to your elbow in....money