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They Catch on Fire – Electrocautery Trephination with Acrylic Nails

April 5, 2022

Written by Sam Parnell

Spoon Feed
Electrocautery trephination of acrylic nail products attached to simulated digits was associated with a high likelihood of ignition (83/200; 41.5%). Based on this limited data, electrocautery trephination of acrylic nails should be avoided to reduce risk of further patient harm.

Why does this matter?
Nail injuries are encountered frequently in the acute care setting, and one of the most common nailbed injuries is the subungual hematoma. Subungual hematomas usually occur after crush injury or blunt trauma and result in accumulation of blood under the nail. This can be associated with significant pain and the potential for functional or cosmetic morbidity.

In the past, large subungual hematomas were managed by nail removal and underlying nailbed laceration repair. However, recent studies have shown that most subungual hematomas can be managed by nail trephination, which appears to be just as efficacious and has the added benefits of being faster, less invasive, and lower risk. Trephination can be accomplished with a hollow tip needle, a heated paper clip, or electrocautery. However, electrocautery of acrylic nails presents an interesting concern, as acrylic has flammable properties. But does electrocautery trephination of acrylic nail products really lead to ignition and the potential for serious burn injury?

Fire in the hole! – trephination hole that is…
This was a small, non-randomized, experimental study using faux fingers, made with acrylic fingernails and consumer-available hot dogs. Electrocautery of the faux fingers with acrylic nails was accomplished using disposable, high temperature, battery-operated Bovie electrocautery pens. A total of 83 out of 200 acrylic nails exposed to electrocautery ignited (41.5% combustion rate). Interestingly, the percentage of acrylic nails that ignited due to trephination varied widely from pen to pen, even though the pens were all the same brand and type. See the figure below from the article showing the faux finger setup with an acrylic nail igniting during trephination with an electrocautery pen.

From cited article – Yummy! Who doesn’t like a good flame kissed hot dog?

This was a small, experimental study that had several limitations. Specifically, it only included one brand of do-it-yourself acrylic nails, and there were significant differences in the ignition rates caused by different electrocautery pens. However, based on these findings, it appears that there is significant risk of ignition and burn injury when using electrocautery to manage acrylic nail trephination. Therefore, I will be avoiding electrocautery in favor of hollow tip needle trephination when caring for patients who have a subungual hematoma and acrylic nails.

Up in Flames: The Safety of Electrocautery Trephination of Subungual Hematomas with Acrylic Nails. West J Emerg Med. 2022 Feb 23;23(2):183-185. doi: 10.5811/westjem.2021.10.53567.

Another Spoonful
See this excellent post on emDocs on subungual hematoma.

What are your thoughts?