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 1. Finger 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 • First Dorsal Metacarpal Artery (FDMA) flap 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
QUESTIONS 1 of 17 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.148) A 45-year-old carpenter sustained a table saw injury to his right hand while at work earlier today. Evaluation in the Emergency Department reveals the defect depicted in Figure A. An island volar advancement flap was selected for wound closure. What is the largest defect that could be covered with this technique? Tested Concept QID: 4508 FIGURES: A Type & Select Correct Answer 1 less than 1 cm 10% (428/4423) 2 1-1.5 cm 10% (458/4423) 3 1.5-2 cm 22% (967/4423) 4 2-2.5 cm 29% (1290/4423) 5 2.5-3.5 cm 28% (1225/4423) L 5 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (OBQ12.186) A 6-year-old girl sustains transverse amputations through her long and ring fingertips after getting her hand caught in a lawn mower. She presents to the emergency room 30 minutes after the injury with the amputated tissue which was placed on ice in a waterproof bag. On physical exam the amputation levels are found to be 6 millimeters distal to the lunula. The wounds are noted to be fairly contaminated with no evidence of exposed bone. Skin defects are less than 1 centimeter. Which of the following is the most appropriate management at this time? Tested Concept QID: 4546 Type & Select Correct Answer 1 Emergent replantation of the amputated parts 8% (473/5696) 2 Revision amputation through the distal interphalangeal joint 2% (101/5696) 3 Thorough irrigation and debridement followed by elective Moberg advancement flaps 6% (323/5696) 4 Thorough irrigation and debridement followed by elective Z-plasty reconstruction 3% (176/5696) 5 Thorough irrigation and debridement, soft dressing application, and follow-up within 1 week 80% (4558/5696) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (OBQ12.213) Which of the following hand injuries seen in Figures A-E is most appropriately treated with a first dorsal metacarpal artery flap? Tested Concept QID: 4573 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 1% (57/4497) 2 Figure B 21% (951/4497) 3 Figure C 73% (3262/4497) 4 Figure D 2% (103/4497) 5 Figure E 2% (72/4497) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (OBQ10.235) Which of the following hand injuries is most appropriately treated with a volar advancement (Moberg) flap closure? Tested Concept QID: 3334 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 4% (143/3776) 2 Figure B 6% (226/3776) 3 Figure C 12% (462/3776) 4 Figure D 76% (2885/3776) 5 Figure E 1% (34/3776) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (OBQ09.48) A 6-year-old boy sustained a finger tip amputation shown in Figure A after grabbing a broken glass out of the dishwasher. Your plan was to perform a bedside irrigation and debridement of the finger after digital anesthetic block and apply antibiotic ointment with a sterile dressing. Upon exploration of the wound you notice that distal phalanx is exposed. Your plan should change to include which of the following treatments? Tested Concept QID: 2861 FIGURES: A Type & Select Correct Answer 1 Homodigital island flap 1% (32/2412) 2 Thenar flap 3% (80/2412) 3 Volar flap advancement 4% (104/2412) 4 V-Y advancement flap 22% (539/2412) 5 No change from your initial plan of ointment and dressing 68% (1635/2412) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (OBQ09.65) You are taking care of an adult patient with significant scar contracture in her first web space after a thermal burn. Which of the following techniques will allow you to lengthen her scar approximately 75%? Tested Concept QID: 2878 Type & Select Correct Answer 1 Cross-finger flap 1% (13/2324) 2 Two-flap Z-plasty with 60 degree limbs 88% (2042/2324) 3 Two flap Z-plasty with 25 degree limbs 9% (199/2324) 4 Island pedical flap 2% (36/2324) 5 Split-thickness skin graft 1% (23/2324) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ06.14) A 28-year-old factory worker has his ring finger caught in the machinery at work. A photograph of the injury is shown in Figure A. Which of the following procedures will best supply coverage of the wound? Tested Concept QID: 25 FIGURES: A Type & Select Correct Answer 1 Amputation through the proximal interphalangeal joint 2% (44/2314) 2 Shortening of the distal phalanx, nail bed removal, and V-Y flap 89% (2053/2314) 3 Cross-finger flap 2% (39/2314) 4 Groin flap 0% (11/2314) 5 Thenar flap 6% (142/2314) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (OBQ05.134) Which of the following complications is most likely to occur following the procedure on the middle finger of a right hand shown in Figure A? Tested Concept QID: 1020 FIGURES: A Type & Select Correct Answer 1 Flap failure 5% (69/1321) 2 Cosmetic mismatch of the skin 8% (101/1321) 3 Median nerve motor branch injury 2% (25/1321) 4 Recipient site sensitivity 7% (97/1321) 5 Flexion contracture at the recipient proximal interphalangeal joint 77% (1020/1321) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (OBQ05.91) A 29-year-old intravenous drug user undergoes irrigation and debridement of a ring finger abscess. After adequate eradication of the infection, he is left with the skin defect shown in Figure A. What is the most appropriate treatment at this time? Tested Concept QID: 977 FIGURES: A Type & Select Correct Answer 1 Local woundcare and healing by secondary intention 7% (195/2618) 2 V-Y advancement flap 6% (146/2618) 3 Thenar flap 6% (150/2618) 4 Moberg flap 4% (104/2618) 5 Cross-finger flap 77% (2008/2618) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (OBQ04.65) A 25-year-old left hand dominant musician sustains an injury to the left thumb shown in Figure A. He is unable to extend the interphalangeal joint and has less than 2 second capillary refill at the thumb. What is the most appropriate method to achieve soft tissue coverage after extensor tendon repair or transfer? Tested Concept QID: 1170 FIGURES: A Type & Select Correct Answer 1 Moberg advancement flap 14% (412/2973) 2 Vacuum-assisted wound closure 2% (51/2973) 3 Wet-to-dry dressings 1% (37/2973) 4 First dorsal metacarpal artery (Kite) flap 79% (2363/2973) 5 V-Y advancement flap 3% (94/2973) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept
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