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https://upload.orthobullets.com/topic/6060/images/fingertip.jpg
https://upload.orthobullets.com/topic/6060/images/fingertip anatomy.jpg
https://upload.orthobullets.com/topic/6060/images/Hand master_moved.jpg
https://upload.orthobullets.com/topic/6060/images/Thenar sequence_moved.jpg
Introduction
  • Injury to the finger with variable involvement of soft tissue, bone, and tendon
  • Goals of treatment
    • sensate tip
    • durable tip
    • bone support for nail growth
  • Prognosis
    • improper treatment may result in stiffness and long-term functional loss
Anatomy
  • Fingertip anatomy
    • eponychium
      • soft tissue on the dorsal surface just proximal to the nail
    • paronychium
      • lateral nail folds
    • hyponychium
      • plug of keratinous material situated beneath the distal edge of the nail where the nail bed meets the skin
    • lunula
      • white portion of the proximal nail
      • demarcates the sterile from germinal matrix beneath
    • nail bed
      • sterile matrix
        • where the nail adheres to the nail bed
      • germinal matrix
        • proximal to the sterile matrix
        • responsible for 90% of nail growth
Presentation
  • History
    • mechanism
      • avulsion
      • laceration
      • crush
  • Physical exam
    • inspection
      • often, characteristics of laceration will guide management
      • presence or absence of exposed bone
    • range of motion
      • flexor and extensor tendon involvement
Imaging
  • Radiographs
    • required imaging
      • AP/lateral radiographs to assess for bony involvement
Treatment
  • Nonoperative
    • healing by secondary intention
      • indications
        • adults and children with no bone or tendon exposed with < 2cm of skin loss
        • children with exposed bone
  • Operative
    • primary closure (revision amputation)
      • indications
        • finger amputation with exposed bone and the ability to rongeur bone proximally without compromising bony support to nail bed
    • full thickness skin grafting from hypothenar region
      • indications
        • fingertip amputation with no exposed bone and > 2cm of tissue loss
    • flap reconstruction
      • indications
        • exposed bone or tendon where rongeuring bone proximally is not an option
Surgical Techniques
  • Secondary intention
    • technique
      • initial treatment with irrigation and soft dressing
      • after 7-10 days, soaks in water-peroxide solution daily followed by application of soft dressing and fingertip protector
      • complete healing takes 3-5 weeks
  • Full thickness skin grafting from hypothenar region
    • technique
      • split thickness grafts not used because they are
        • contractile
        • tender
        • less durable
      • donor site is closed primarily
      • graft is sutured over defect
      • cotton ball secured over graft helps maintain coaptation with underlying tissue
    • post-operative care
      • cotton ball removed after 7 days
      • range of motion encouraged after 7 days
  • Primary closure with removal of exposed bone (revision amputation)
    • technique
      • must ablate remaining nail matrix
        • prevents formation of irritating nail remnants
      • if flexor or extensor tendon insertions cannot be preserve, disarticulate DIP joint
      • transect digital nerves and remaining tendons as proximal as possible
      • palmar skin is brought over bone and sutured to dorsal skin
  • Flap reconstruction (see below)
Flap Techniques By Region
  • Flap treatment options determined by location of lesion

 1Finger Tip
Straight or Dorsal Oblique laceration
 • V-Y Advancement flap 
 • Digital island artery 
Volar Oblique laceration
   • Cross finger flap (if > 30 yrs) 
   • Thenar flap (if< 30 yrs) 
   • Digital island artery
  • reverse cross finger (for nail bed sterile matrix and eponychial fold losses) 
 2. Volar Proximal Finger
   • Cross finger (if > 30 yrs)

   • Axial flag flap from long finger
 3. Dorsal Proximal Finger & MCP
   • Reverse cross finger 
 
   • Axial flag flap from long finger    
 4. Volar Thumb
   • Moberg Advancement Volar Flap (if < 2 cm)  

   • FDMA (if > 2 cm)  
   • Neurovascular Island Flap (up to 4 cm)    
 5. Dorsal Thumb
   • FDMA    
 6. First Web Space
   • Z-plasty with 60 degree flaps 
   • Posterior interosseous fasciocutaneous flap (if > 75%)  
 7. Dorsal Hand
   • Groin Flap    
 
Flap Reconstruction Techniques
  • V-Y advancement flap   
    • indications
      • straight or dorsal oblique finger tip lacerations
  • Digital island artery
    • indications
      • straight or dorsal oblique finger tip lacerations
      • volar oblique finger tip lacerations
    • advantages
      • best axial pattern flap
  • Cross finger flap   
    • indications
      • volar oblique finger tip lacerations in patients > 30 years
    • advantages
      • leads to less stiffness
  • Reverse cross finger flap
    • indications
      • dorsal finger & MCP lacerations
  • Thenar flap  
    • indications
      • volar oblique finger tip lacerations to index or middle finger in patients < 30 years
    • advantages
      • improved cosmesis
  • Axial flag flap from long finger 
    • indications
      • volar proximal finger
      • dorsal proximal finger & MCP lacerations
  • Moberg advancement volar flap   
    • indications
      • volar thumb if < 2 cm
  • Neurovascular island flap    
    • indications
      • volar thumb up to 4 cm
  • First dorsal metacarpal artery flap
    • indications
      • dorsal thumb lacerations
      • volar thumb lacerations if > 2 cm
    • technique
      • based on 1st dorsal metacarpal artery
  • Z-plasty with 60 degrees flaps 
    • indications
      • first web space lacerations
    • technique
      • can lead up to 75% increase in length
  • Posterior interosseous fasciocutaneous flap
    • indications
      • first web space lacerations
  • Groin flap 
    • indications
      • lesions to dorsal hand
Complications
  • Flap failure
    • cause
      • inadequate arterial flow
        • vasospasm often leads to thombosis at anastamosis
      • inadequate venous outflow
  • Hook nail deformity
    • cause
      • tight tip closure
      • insufficient bony support
    • treatment
      • variety of reconstructive procedures have been described
 

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