Updated: 10/24/2018

Fingertip Amputations & Finger Flaps

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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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Questions (15)
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(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? Review Topic

QID: 4508
FIGURES:
1

less than 1 cm

10%

(417/4015)

2

1-1.5 cm

10%

(397/4015)

3

1.5-2 cm

20%

(789/4015)

4

2-2.5 cm

30%

(1205/4015)

5

2.5-3.5 cm

29%

(1156/4015)

L 5

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(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? Review Topic

QID: 4546
1

Emergent replantation of the amputated parts

8%

(423/5217)

2

Revision amputation through the distal interphalangeal joint

2%

(88/5217)

3

Thorough irrigation and debridement followed by elective Moberg advancement flaps

6%

(294/5217)

4

Thorough irrigation and debridement followed by elective Z-plasty reconstruction

3%

(152/5217)

5

Thorough irrigation and debridement, soft dressing application, and follow-up within 1 week

81%

(4205/5217)

L 2

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(OBQ12.213) Which of the following hand injuries seen in Figures A-E is most appropriately treated with a first dorsal metacarpal artery flap? Review Topic

QID: 4573
FIGURES:
1

Figure A

1%

(56/4096)

2

Figure B

22%

(892/4096)

3

Figure C

72%

(2939/4096)

4

Figure D

2%

(96/4096)

5

Figure E

2%

(63/4096)

L 3

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(OBQ10.235) Which of the following hand injuries is most appropriately treated with a volar advancement (Moberg) flap closure? Review Topic

QID: 3334
FIGURES:
1

Figure A

4%

(120/3328)

2

Figure B

6%

(192/3328)

3

Figure C

12%

(404/3328)

4

Figure D

77%

(2562/3328)

5

Figure E

1%

(29/3328)

L 2

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(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? Review Topic

QID: 2861
FIGURES:
1

Homodigital island flap

1%

(22/2015)

2

Thenar flap

3%

(60/2015)

3

Volar flap advancement

4%

(84/2015)

4

V-Y advancement flap

20%

(408/2015)

5

No change from your initial plan of ointment and dressing

71%

(1422/2015)

L 3

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(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%? Review Topic

QID: 2878
1

Cross-finger flap

1%

(10/1992)

2

Two-flap Z-plasty with 60 degree limbs

89%

(1766/1992)

3

Two flap Z-plasty with 25 degree limbs

8%

(164/1992)

4

Island pedical flap

1%

(28/1992)

5

Split-thickness skin graft

1%

(15/1992)

L 1

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(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? Review Topic

QID: 25
FIGURES:
1

Amputation through the proximal interphalangeal joint

2%

(40/2070)

2

Shortening of the distal phalanx, nail bed removal, and V-Y flap

89%

(1838/2070)

3

Cross-finger flap

2%

(36/2070)

4

Groin flap

0%

(8/2070)

5

Thenar flap

6%

(127/2070)

L 2

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(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? Review Topic

QID: 1020
FIGURES:
1

Flap failure

5%

(52/1007)

2

Cosmetic mismatch of the skin

8%

(79/1007)

3

Median nerve motor branch injury

2%

(21/1007)

4

Recipient site sensitivity

8%

(80/1007)

5

Flexion contracture at the recipient proximal interphalangeal joint

76%

(770/1007)

L 2

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(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? Review Topic

QID: 977
FIGURES:
1

Local woundcare and healing by secondary intention

8%

(169/2182)

2

V-Y advancement flap

5%

(115/2182)

3

Thenar flap

6%

(123/2182)

4

Moberg flap

4%

(87/2182)

5

Cross-finger flap

77%

(1678/2182)

L 2

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(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? Review Topic

QID: 1170
FIGURES:
1

Moberg advancement flap

14%

(378/2674)

2

Vacuum-assisted wound closure

2%

(48/2674)

3

Wet-to-dry dressings

1%

(34/2674)

4

First dorsal metacarpal artery (Kite) flap

79%

(2113/2674)

5

V-Y advancement flap

3%

(87/2674)

L 2

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