FINGER TIP INJURY

Definition

Injuries to the fingertip area which are distal to the insertion of the flexor & extensor tendons

IntroductionMost common injuries of the hand

Although maintenance of length preservation of nail important appearance

But, primary goal of treatment:painless fingertip with durable & sensate skin

Introduction

Methods of treatment:Healing by secondary intentionSkin graftingShortening of the bone & primary closureLocal & regional flapComposite reattachmentMicrosurgical replantation (very rare)

Anatomy of Fingertip

Anatomy of Fingertip

Mechanism of InjuryMechanism of injury:crushingclean amputation

Also: mixed mechanism of injury.

ClassificationClassification of Allen for Amputations of the Fingertip

(Allen MJ. Conservative management of finger tip injuries in adults. The Hand. 1980; 12: 257-265)

TypeAnatomic Site for Amputation Idistal to fingernail tipIIdistal to tip of distal phalanx (involves distalmost nail bed)IIIdistal to mid-distal phalanxIVdistal to distal PIP joint (entire distal phalanx)

Classification(Rosenthal EA. 1983. Treatment of fingertip and nail bed injuries.Orthop Clin North Am 14: 67597)

Classification(Van Beek AL, Kassan MA, Adson MH, Dale V. 1990. Management of acute fingernail injuries. Hand Clin 6:2335; discussion 3738)

General Principles of Evaluation & Treatment

History taking:Mechanism of injuryAge GenderHandednessOccupationAvocationHistory of previous hand problem & systemic disease

General Principles of Evaluation & TreatmentWhich finger??

Complete hand examinationSkinVascularityNeurologic functionFlexor & extensor tendon function

Characteristics of the wound

X-rays

AB & tetanus prophylactic

General Principles of Evaluation & Treatment

General Principles of Evaluation & Treatment

If more than one treatment option discuss w/ px

Simplest method should be selected

Many managed in ER

Bloodless field

Meticulously debrided & irrigated

General Principles of Evaluation & TreatmentAny loss of skin / pulp, amount of it

Exposed bone / fracture

Injury to nail bed / perionichial tissue

Level & angle of injury

No loss simple closure (loosely)

Important Basic PrinciplesPrepare the extremity to the proximal forearm and any potential graft donor sites.Undertake meticulous wound toilet, surgical washout and appropriate yet minimal debridement.Ensure accurate apposition and repair of the lacerated nail bed.Replace like with like tissue if considering a graft.Preserve skin folds surrounding nail margins. Prevent adhesions within nail folds (especially between the eponychial fold and underlying nail bed).Fractures should be accurately reduced. Ensure a flat surface that is long enough for nail growth.Restore finger skin and pulp if feasible.Excise all remnants of the germinal matrix if terminalization is considered.(Klienert et al., 1967)

Soft Tissue Loss Without Exposed Bone

Appropriate treatment: Skin graftHealing by secondary intention

Still controversy

Soft Tissue Loss Without Exposed BoneSmaller wounds ( 1cm2) open method, because of its simplicity

Complete healing: 3-5 weeks by wound contraction & epithelialization

7-10 days after injury begin soaking w/ warm water + peroxide solution

Desensitization initiated

Suitable for children

Soft Tissue Loss Without Exposed BoneLarger wounds if conservative: not durable, so consider skin graft

Should be full-thickness:Contract lessMore durableLess tenderBetter sensibility

Taken from ulnar border of the hand (glabrous skin)Width: up to 2 cmAfter 7 days start ROM exerciseShould not be used indiscriminately

Soft Tissue Loss With Exposed BoneSatisfactory coverage must be obtained

Composite tip graft only for < 6 y.o

Open method; nail plate deformities

Coverage by Shortening the bone w/ primary closure (revision amputation)Local flapRegional flap

Soft Tissue Loss With Exposed BoneBased on:Level & angle of amputationAge sex

Revision AmputationIndication:When not enough sterile matrix remain (< 5 mm)Advanced ageSystemic condition

Remaining nail matrix ablated

If flexor & extensor tendons insertion cant be preserved disarticulation

Revision AmputationTendons transected & allowed to retract

Prevent painful neuroma

Prominent volar condyle of middle phalang, collateral ligament & volar plate trimmed

Oblique angle (sagittal) use to cover bone

Local FlapsAdvantages:Can be used for any agePreserve lengthDo not requires skin graftSimilar quality, texture & colourEarly ROM

Requires judgement & expertise

Most commonly used:V-Y / Triangular Volar / Atasoy FlapKutler / Bilateral V-Y Flap

V-Y / Triangular Volar / Atasoy Flap

Transverse / dorsal oblique amputations

Can be used for all digits

Only 1 cm advancement

Not for too proximal amputation

Trim the bone

Not to damage neurovascular bundle

All fibrous septa must be divided

V-Y / Triangular Volar / Atasoy Flap

Kutler / Bilateral V-Y FlapMost appropriate for distal transverse amputation

Dual triangular flap from the lateral side

Without undermining

Disadvantages: small & difficult to advanceFlap necrosisNail deformityHipersensitivity

Regional FlapsMost commonly used:Cross-finger flapThenar flap

Preserve length

Volar oblique angle

Too proximal amputation

More than 1 finger combination

Regional FlapsDisadvantages:2-stage procedureProlonged immobilization joint stiffness (not for age > 40)Cross-finger flap donor-site scar: not suitable for female & dark-skinned persons

Contraindicated in:OA of the hands or arthritisSystemic condition: RA, DM, vasospastic disorders

Regional Flaps

Post-op:Bulky dressingSplintUninjured finger left freeFlap division 12-14 days afterSuturing recipient cut edge: not recommendedAggressive ROM program

Cross-finger FlapHinge side: adjacent to injured finger

Through subcutaneous tissue

Preserve paratenon

FTSG from groin to cover donor-site

Can be proximally, distally or laterally based

Satisfactory 2-point discrimination (8-10 mm), some had impaired tactile gnosia

Cross-finger Flap

Thenar FlapCan be used for any finger, but small finger difficult

Disadvantages:PIP stiffnessTenderness over donor-site

Location: high on thenar eminence

Radial border parallel & adjacent to MCP crest

Proximally based

Thenar FlapAs wide as 2 cm; 1,5x wider than defect

Not to damage radial digital nerve of the thumb

Donor defect: FTSG

Position: MCP & DIP flexed as much as possible

Injury of The ThumbSimilar to other digits

Importance of length preservation & restoration of sensibility magnified

Choices:Moberg FlapCross-finger FlapKite FlapLittler Flap

Moberg Advancement Flap

Indication:Can not be flapped w/ V-Y flap> 2 cm defect

Preserve length & tactile gnosia

Containing neurovascular bundle

Transverse incision

Disadvantages: Flexion deformity

Moberg Advancement Flap

Cross-finger Flap

Donor from index finger (prox phalang) or other finger

For loss of > 2/3 pulp tissue

Innervation can be augmented by neurorraphy

First Dorsal Metacarpal Artery-Island Pedicle Flap (Kite Flap)

1 stageInclude neurovascular bundleBased on 1st dorsal MC ArteryDonor: FTSG

***************************************