FINGERTIP AND NAIL BED INJURIES

FINGERTIP INJURIES
Fingertip injuries are defined as those injuries occurring distal to the insertion of
the flexor and extensor tendons. They are the most common injuries of the hand
and can lead to a significant functional and cosmetic deficit if they are not
treated appropriately. The fingertip is the end organ for touch and is richly
supplied with special sensory receptors that enable the hand to relay the shape,
temperature, and texture of an object. The glabrous skin of the fingertip is
specially adapted for pinch and grasp functions. Its volar surface consists of a
fatty pulp covered by highly innervated skin. The skin of the fingertip is firmly
anchored to the underlying terminal phalanx by multiple fibrous septa that
traverse the fatty pulp.
After a fingertip injury, restoration of sensibility, stable skin coverage, and
adequate padding are the goals of reconstruction. There are many treatment
options, which range from allowing the wound to heal by secondary intention to
flap coverage or revision amputation. No single procedure can be recommended,
but each case must be individualized depending on the needs of the patient and
the type of injury (19,32). Patient-related factors that should be considered
include age, occupation, avocation, and general health. Injury-related factors
include associated nail bed injuries, angle of injury, bone exposure, digit injured,
and concomitant injuries.
This section reviews the common procedures performed for this injury. It
discusses the indications, advantages, and disadvantages of each procedure,
along with a treatment algorithm.
CLASSIFICATION OF FINGERTIP INJURIES
Allen has classified fingertip injuries into four types based on the level of injury
(1). Type 1 injuries involve only the pulp, and type 2 injuries involve the pulp and
nail bed. Type 3 injuries include partial loss of the distal phalanx, whereas type 4
injuries are proximal to the lunula. This classification is useful because it allows
the surgeon to help organize treatment options (Fig. 38.1). For example, type 1
injuries may heal quite well by secondary intention. In contrast, types 3 and 4
often require some type of flap coverage. Injuries must also be thought of in
terms of whether bone is exposed and the angulation of injury. There are three
general terms used to describe the angulation of injurydorsal oblique,
transverse, and volar oblique (Fig. 38.2). In general, dorsal oblique and
transverse injuries are more suited to local flaps. Volar oblique flaps often require
a regional flap. By considering all of these factors for each patient, a rational
treatment plan can be initiated.

HEALING BY SECONDARY INTENTION

The simplest treatment of fingertip injuries is to allow the wound to heal by
secondary intention. This method relies on reepithelialization and contracture to
provide wound closure. It is reserved for small defects (6 to 8 mm) without
exposed bone and with minimal loss of pulp tissue. In young children this method
provides good results even if bone is exposed.

Begin treatment with a thorough debridement of the wound, which can be

performed under local anesthesia in the emergency room.

Perform local wound care two to three times daily with dressing changes.
Healing is usually completed by 3 to 6 weeks depending on the size of the
defect.

Chow and Ho reported good results in their series of patients treated in this
manner (7). They noted that very few patients had pain or limited range of
motion at 6 months from injury, although there was a 27% incidence of nail
deformity. Other complications of this treatment method include delayed healing,
pyogenic granuloma, cold intolerance, and stump tenderness. One should realize
that the missing tissue is replaced by scar. Owing to the deficient tissue, the tip
can become quite sensitive and therefore patients who use their fingertips
repetitively during work are poor candidates for this technique.
COMPOSITE GRAFTS

If the amputated part is clean and the tissue is of adequate integrity, use the
part for soft-tissue coverage. If there is no exposed bone, defat the skin and
suture it into the defect. The defatting is extremely important, because this piece
will now act as a free skin graft. Minimize its thickness to enhance its chances of
taking. This skin, however, may necr ose and then would serve as a
biologic dressing. The chance of success with this treatment is greater when
used in children.
In children younger than 3 years old, we consider reattaching the amputated
part as a composite graft (28). This is because children of this age have the
extraordinary ability to heal these injuries. Elsahy reattached amputated
fingertips without a microvascular anastomosis in 35 patients; subsequent
survival was correlated with the level of injury (11). Tip amputations without nail
bed involvement (Allen Type 1) survived in four of five patients. In contrast, only
2 of 10 amputations proximal to the lunula (Allen Type 4) survived. The major
complication of this procedure is the necroses of the composite graft. If the finger
is amputated 2 mm proximal to the lunula, then replantation can be considered.
Microvascular anastomosis is difficult at this level. This procedure can give better
cosmetic and functional results when compared with terminalization and revision
amputation.
REVISION AMPUTATION
A simpler course of action involves shortening of the digit or revision amputation.
This procedure is indicated in situations in which minimal bone is exposed and
the angle of the injury is such that other options are not appropriate. Take care to
limit loss of length, particularly in treating the thumb. This procedure can be
performed under local anesthesia in the emergency room if minimal bone
shortening is required. Develop the flaps to cover the tip of the digit, preferably
with volar skin. Use the volar skin rather than the dorsal skin to provide a more
padded and durable soft tissue cover for the fingertip. Patients can return to their
activities as tolerated when the soft tissues have healed.
SKIN GRAFTS
Skin grafts can be used in injuries where there is skin loss but adequate
subcutaneous tissue is present with no exposed bone. The lack of exposed bone
is paramount, because skin grafts will not take on bone. Use this
technique for injuries with skin loss of greater than 1 cm. In cases of smaller skin
defects, allow the wound to heal by secondary intention, as previously described.
Skin grafts can be divided into split thickness or full thickness. Full-thickness
grafts provide better sensibility and durability, as well as a better cosmetic
result. On the other hand, split-thickness skin grafts have a greater likelihood of
taking. Idler and Strickland recommend split-thickness grafts because of
their ability to contract and draw in normal tissue with a greatly reduced size of
the defect (19). Take split-thickness skin grafts of 0.012 to 0.015 inches thick.
Harvest smaller split thickness grafts free hand from the glabrous skin of the
hypothenar eminence. Take larger grafts from the thigh or buttocks. Harvest fullthickness skin grafts locally from the palmar wrist crease or from the hypothenar

area (Fig. 38.3A, Fig. 38.3B). The palmar wrist crease provides an area of
approximately 2 6 cm, whereas the hypothenar skin provides an area of 2 to
2.5 cm in width by 6 to 8 cm in length. Harvest larger amounts of full-thickness
skin grafts from distant sites such as the hairless area of the groin. The donor
site in a full-thickness graft is typically closed primarily. Excellent hemostasis of
the injury site must be obtained to avoid the postoperative complication of
hematoma formation. Secure the graft with a bolus stent type of dressing that is
left undisturbed for 5 to 7 days. Start therapy after the dressing is removed.

Complications from this procedure include hematoma, necrosis of the skin graft,
and donor site complications.
LOCAL FLAPS
Local flaps use adjacent local skin with its subcutaneous tissue and normal
sensory end organs to cover defects. There are two common advancement flaps
used for fingertip injuries. Both share similar principles in that a V incision is
made adjacent to the defect. Atasoy and colleagues popularized the V-Y
advancement flap in which the incision is made palmar, and Kutler described a
similar flap in which the incisions are made laterally (2,22). The skin and
subcutaneous tissues are advanced forward, and the proximal defect is closed
end to end. After closure, the proximal portion of the wound forms the vertical
line of the Y. Range of motion therapy is started 7 to 10 days following either
local advancement flap as the wound permits. Another local flap is the
homodigital triangular flap, which is dissected more proximally and the digital
artery is included within the flap. Lanzetta et al. have recently described good
results using this technique for volar oblique amputations (23).
V-Y Advancement Flap
The V-Y advancement flap that was popularized by Atasoy et al. is used in
fingertip injuries with dorsal angulation (2). It can be used for transverse
amputations, although it is more difficult in this setting. The procedure is,
however, contraindicated in palmarly angulated injuries.

Make the incisions with the apex of the V at the midpalmar distal
interphalangeal joint and the arms of the V extending to the widest portion
of the amputation (Fig. 38.4B).

Incise the skin, leaving the subcutaneous tissues intact.

Release the fibrous septa connecting the flap to the underlying bone. This
allows maximum mobilization and keeps the flap's blood and nerve supply
intact.

Use gentle traction with skin hooks to advance the flap into the defect.

Release all tension so that suturing the distal margin of the flap is done
without blanching (use small monofilament surture, 6-0 or 7-0). This
avoids potential tip necrosis.

Close the remaining donor defect side to side. This flap provides like tissue
with good color and sensory characteristics.

Complications of this procedure include necrosis of the flap, hypesthesias,

dysesthesias, impaired sensation, and cold intolerance.
V-Y Kutler Flap
The Kutler V-Y flap is also useful for transverse amputations (13,22,35). The
design of this flap is similar to the V-Y advancement flap in that the apex is at the
distal interphalangeal (DIP) joint and the base at the amputation site, although in
this procedure the flap is placed laterally. The flaps can be elevated on one or
both sides of the digit. Care again must be taken to divide the fibrous septa and
preserve the neurovascular supply of the flap (Fig. 38.5).

Plan bilateral flaps with the apices of the triangles in the midlateral line of
the distal interphalangeal flexion crease.

Make the incisions to the level of the fibrous septal attachments at the
bony phalanx, using traction distally with a skin hook to release proximal
septa so flaps advance to the midline (Fig. 38.5B).

Begin tension-free closure with small

monofilament suture.

Complete closure with several interrupted absorbable sutures at the

amputated nail bed margin (Fig. 38.5D).

(6-0 or 7-0) nonabsorbable

The disadvantage of this flap is the limited advancement and the resultant
suture line lies over the pulp. This factor has likely led to the hypersensitivity
noted by some patients. The two advancement flaps have similar complications
including numbness, cold intolerance, and dysesthesias.
REGIONAL FLAPS
Regional flaps are defined as flaps taken from other parts of the hand that do not
use tissue adjacent to the defect. This section discusses the cross-finger and
thenar flap, which are considered for injuries not amenable to local flaps. They
are well suited for volar oblique type injuries. The cross-finger flap can also be
used in treating more proximal soft-tissue injuries of the finger. Owing to the
postoperative immobilization required, the procedures are discouraged in
patients predisposed to finger stiffness. This includes patients older than 50
years of age, patients with rheumatoid arthritis, and patients with multiple
injured digits. These flaps are also not well suited for young children because of
lack of compliance and simpler methods are usually adequate.
Cross-Finger Flap
The cross-finger flap is a random pattern flap taken from the dorsum of the
adjacent finger to resurface a palmar defect. Do not use this flap in patients with
vasospastic disorders including Buerger's disease and Raynaud's phenomenon
(6,8,17).

Create a template for the defect, drawing the pattern on the dorsum of the
adjacent digit over the middle phalanx. Base the flap on the lateral aspect
of the adjacent finger. The flap may be dissected from the midlateral line
of the lateral aspect of the adjacent finger to the midlateral line medially
as required to encompass the size of the defect.

Carry down the dissection through the subcutaneous tissues, taking care
not to disturb the paratenon of the extensor mechanism. Leave the
paratenon intact to allow skin grafting of the donor site.

Also leave undisturbed the dorsal veins within the flap.

Cleland's ligaments, however, may need to be divided to provide full

mobility. An innervated flap can be accomplished by including a dorsal
cutaneous nerve branch, which is then sutured to the proper digital nerve.

After the flap is raised, deflate the tourniquet. Obtain hemostasis to

prevent hematoma formation.

Inset the flap and trim appropriately (Fig. 38.6). Suture the flap into the
recipient finger defect, using an interrupted half-buried mattress
monofilament suture (6-0 or 7-0). Cover the donor site with a full-thickness
skin graft that is sutured to the hinged portion of the flap. Secure the skin
graft with a bolster dressing and immobilize the digits in a position that
places the least tension on the flap. This is usually in the intrinsic plus
position. Kirschner wires are rarely needed to maintain this position.

Divide the flap and inset at 10 to 14 days postoperatively. Begin therapy

soon after flap division. Be careful not to divide the flap too close to the
recipient side in order to allow the flap to be inset more easily. This is a
reliable flap, but there is usually a color mismatch at both the donor and
recipient sites. One can expect protective sensation postoperatively, with
two-point discrimination often twice normal.

Reverse Cross-Finger Flap

The reverse cross-finger flap is more commonly used for dorsal finger defects.

Design the flap with its base at the midaxial line of the middle phalanx of
the donor finger.

Elevate the skin of the donor finger as a full-thickness skin graft and
separate from the subcutaneous tissues. The base of this skin is opposite
to the defect. Elevate the subcutaneous tissue on the dorsum of the donor
finger as a flap, with its base hinged adjacent to the defect, leaving the
paratenon again intact.

Inset this flap into the defect and sew the skin back over the donor site.
Then create a skin graft for the flap of subcutaneous tissue that has been
transferred to the recipient finger defect.

Apply a bolus stent-type dressing.

Place the skin graft over the transferred subcutaneous tissue (Fig. 38.7).

To illustrate the use of a cross-finger or reverse cross-finger flap, a defect located

on the palmar aspect of the long finger could be treated with a standard crossfinger flap. The donor finger would be the ring finger, and the flap would be
hinged radially. The donor site would then be skin grafted. If the defect of the
long finger was dorsal, a reverse cross-finger flap would be performed. The donor
finger, however, would be the index finger and the flap would be hinged ulnarly.
In this procedure, the recipient finger requires skin grafting.
Thenar Flap
The thenar flap has similar indications and contraindications as the cross-finger
flap. The procedures are best suited for volar fingertip defects.

Elevate this random pattern flap from the thenar eminence and hold the
involved finger in flexion for insetting of the flap. Placing the flap ulnarly
on the thenar eminence has been associated with scar tenderness. Base
the flap proximally, distally, or radially dependent on the defect (Fig.

38.8A). The distal border should be parallel and adjacent to the

metacarpophalangeal (MP) joint crease. The flap should be 1.5 times the
width of the defect. This allows the soft tissue of the finger to assume a
more rounded and normal appearance.

Once the flap is outlined, dissect the skin and subcutaneous tissues off the
thenar musculature.

Take care not to injure the radial digital nerve or recurrent branch of the
median nerve.

Close the flap donor site primarily in a linear fashion with interrupted
monofilament sutures, or cover with a full-thickness skin graft (Fig. 38.8B,
Fig. 38.8C). Smith and Albin described an H-type thenar flap (40). In this
procedure, fill the donor defect by advancing the remaining half of the H
(Fig. 38.9). Approximate the raised flap to the amputation site by palmarly
abducting the thumb and flexing the MP joint and the distal
interphalangeal joint of the recipient finger. This minimizes the amount of
proximal interphalangeal (PIP) flexion required for immobilization to less
than 40 to 50 and decreases the risk of a PIP flexion contracture.

Divide the flap at 10 to 14 days postoperatively. The base of the pedicle on

the thenar eminence may be trimmed of excessive tissue, but usually
neither the donor site nor the recipient finger requires further insetting.

Start active flexion and extension exercises immediately.

The major criticism of this flap in the past has been a PIP flexion contracture and
tenderness at the donor site. Melone et al. analyzed 150 cases and
recommended designing the flap high on the thenar eminence and not on the
palmar aspect of the hand (26). In Melone's series, the average 2-point
discrimination was 7 mm. In addition, the donor site was an infrequent source of
pain. Only 4% of patients developed a flexion contracture, none of which were
believed to be related to the procedure.
DISTANT FLAP COVERAGE
Distant flaps are defined as flaps obtained from areas of the body other than the
injured limb. These procedures are considered in hand injuries with large softtissue defects and provide thick, fatty coverage with little sensibility. The flaps
can be developed from the chest, abdomen, groin, or opposite arm.
THUMB COVERAGE
The thumb plays a crucial role in prehension and is involved in 50% of the
function of the hand. Preservation of length of the thumb is more important
functionally than in any other digit. Procedures used for thumb coverage
described in this section include the Moberg advancement flap, cross-finger flap,
palmar cross-finger flap, and neurovascular island flaps.
Moberg Advancement Flap
The Moberg advancement flap involves advancement of the volar skin with its
subcutaneous tissues and neurovascular bundles distally into a thumb tip defect
(27,30). The unique anatomy of the thumb makes this flap more suitable for the
thumb than the other digits. There is a risk of a flexion contracture
postoperatively, but the thumb has only one interphalangeal joint, and a flexion
deformity of this joint causes little functional deficit. The fingers, however, have
two interphalangeal joints, and a flexion contracture of the proximal
interphalangeal joint imparts a significant disability. Other differences between
the thumb and fingers include their respective blood supplies. A component of
the blood supply to the thumb arises from the first dorsal metacarpal artery. The
thumb is less dependent on the volar blood supply. In contrast, the fingers rely
more on the volar blood supply and, therefore, risk tip necrosis with this flap. The
volar advancement flap has many advantages over other local, regional, and
distant flaps. It provides immediate restoration of essentially normal sensation
with preservation of length. It can be done in a single stage with low donor site
morbidity. The pulp contour is restored, and the rehabilitation time is relatively
short. In contrast to a neurovascular island flap, no cerebral cortical
programming is needed.

This flap is well suited to the volar oblique amputation of the thumb that is
1 to 1.5 cm in length. The surgical technique involves skin incisions on
both the radial and ulnar midaxial lines. Make these incisions dorsal to the
neurovascular bundles. Extend the incision proximally to the MP flexion
crease or proximal phalanx (Fig. 38.10A). The incision can be extended
further proximally to the thenar eminence for larger defects.

Elevate the flap from the flexor sheath and flex the thumb at the
interphalangeal and MP joints to allow coverage of 1 cm defects (Fig.
38.10). Contour the flap when insetting it. The flap may be sutured to the
nail. If the skin blanches, more proximal dissection is needed.

Make a transverse incision at the base of the flap to allow further

advancement to cover defects up to 1.5 cm. The resulting defect on the
thenar eminence can then be covered with a skin graft.

Other variations of the procedure to gain length include a V-Y advancement at

the base or bilateral Z-plasties along the longitudinal incisions (10). In addition,
Dellon has described a modification that can be made up to 3 cm in length by
using rotational flaps proximally (9). Results of the Moberg advancement flap
have shown excellent return of sensitivity within two-point discrimination with 2
mm of the contralateral fingertips.
Cross-Finger Flap for Thumb Defects
Cross-finger flaps for thumb injuries can be performed using a number of
variations. This includes a standard cross-finger flap, a cross-finger flap including
a branch of the superficial radial nerve with or without neurorrhaphy, and a
palmar cross-finger flap. In treating thumb injuries, the index finger is used as
the donor site for the standard cross finger flap and the long finger is used for
the palmar cross finger flap (3,18,43,44). The importance of a sensate thumb tip
has led to the use of innervated flaps. One option is a cross-finger flap that
includes a branch of the superficial radial nerve.

Raise the flap from the dorsal aspect of the proximal phalanx of the index
finger. Dissect the superficial radial nerve branches and protect them
proximally.

Make a V-type incision with one limb along the radial midlateral line of the
index finger and extending proximally along the second metacarpal.

Make the other limb of the incision from the ulnar side of the defect of the
thumb. Inset the flap and transfer the sensory nerve branches to the
thumb incision.

Use a full-thickness graft to resurface the donor site.

Detach the flap at 3 weeks.

Walker et al. found that performing a first web space Z-plasty at the time of
division can avoid a first web contracture (44). One can modify this procedure by
transecting the dorsal radial sensory nerve branch more proximally and
performing a neurorrhaphy with the ulnar digital nerve of the thumb. These
procedures have the obvious advantage of bringing an innervated pedicle to the
thumb. In Walker's series, all had cortical adaptation, but when carefully asked
three of five patients had sensation referred to the dorsal index finger. They
found that most patients had good sensation that may have been a combination
of median and radial nerve sensation. They also found that the ulnar aspect of
the flap had better sensory recovery than the radial aspect.
Palmar Cross-Finger Flap
A palmar cross-finger flap has been described for injuries of the distal thumb.
The surgical technique is similar to the standard cross-finger flap except the
palmar skin is elevated for the flap. When used for the distal thumb, the long
finger is often the donor site.

Design the flap on the palmar surface of the middle phalanx. Its base
should lie along the ulnar border in the midaxial line (Fig. 38.11A).

Elevate the flap just superficial to the flexor sheath, taking care to
preserve the ulnar neurovascular bundle and to not separate the flap from
the radial neurovascular bundle (Fig. 38.11B).

Suture the flap into place with a fine monofilament suture and suture a
full-thickness skin graft over the donor middle phalanx. Apply a bolus
dressing.

Complete the repair.

Advantages of this procedure, as advocated by Vlastou et al., include better

quality of skin because it is taken from the palmar surface (43). In addition, both
digits are positioned in a more comfortable posture, which may decrease PIP joint
stiffness. Cosmesis is also improved because the scar is on the palmar surface as
compared with the more obvious dorsal surface of the donor digit. The risks of
this procedure include exposing the tendon flexor sheath, stiffness, a painful
donor site, and the potential for neurovascular injury. These complications have
limited its use.

Neurovascular Island Flaps

The neurovascular island flap transfers the soft tissue of the border of a finger
with its neurovascular bundle to the thumb. This technique sacrifices sensation
in a finger of less importance to transfer sensate soft tissue to the thumb. It can
be performed as a primary or reconstructive procedure. The donor site is often
the ulnar border of the long finger, although one may also use the ulnar or radial
aspect of the ring finger (24).

Preoperatively, it is important to assess the arterial flow of the donor

finger and the digit adjacent to the flap because the adjacent vessel is
ligated. After the recipient site is prepared, dissect the digital nerves of the
thumb to the muscle bellies of the flexor pollicis brevis and transect at this
point. The deep location of the nerves helps prevent neuroma formation.

Outline the donor site flap 3 to 4 mm proximal to the midline of the nail
plate. The more distal the flap on the donor finger, the better the
sensitivity in the recipient thumb. Carry the incision proximally along the
midlateral line and palmar aspect of the hand. The distal margin of the
flexor retinaculum marks the proximal portion of the incision. If the
anatomy is normal, dissect from proximal to distal.

Confirm that the common digital artery arises from the superficial arch
and not the deep arch. Take care not to skeletonize the neurovascular
bundle but, rather, take the neurovascular bundle as a unit with the
subcutaneous tissue. This minimizes the risk of injury to the vessels.

Ligate the digital artery branch to the adjacent finger and longitudinally
separate the common digital nerve of the web space. Continue to dissect

proximally to the superficial palmar arch. Then pass the neurovascular

bundle beneath the digital nerve and transfer it to the thumb.

Make a wide tunnel superficial to the palmar fascia. Then place a penrose
drain from the thumb and passing into the palmar defect. Place the flap
inside the penrose drain and transfer to the thumb.

After suturing the flap into place, assess its viability. If flow is not
adequate, ensure that there is no kinking of the vascular pedicle.

Treat the donor site defect with a combination of primary closure and fullthickness skin graft (Fig. 38.12).

The results of this operation have been mixed. Some authors have reported a
deterioration of two-point discrimination with time. Others believed that this
deterioration can be minimized with meticulous technique (41). The flap requires
some cortical reorientation, which is not always complete.
First Dorsal Metacarpal Artery Flap
The first metacarpal artery flap restores sensate skin to the volar thumb in a onestage procedure without the need for microvascular repair. Sherif has reviewed
the anatomy of the first dorsal metacarpal artery (FDMA) and found the artery
present in all cases (38) (Fig. 38.13). The artery originates from the radial artery,
just distal to the extensor pollicis longus before the radial artery dips in between
the two heads of the first dorsal interosseous muscle. He also found that the
FDMA gave off three consistent branches: a radial branch, an ulnar branch, and
an intermediate branch. Furthermore, a cutaneous branch was always present
and originated from either the radial artery or the first dorsal metacarpal artery.
The FDMA is superficial to the dorsal interosseous fascia and is covered by some
fibers of this layer. Before making the incision, a Doppler scan may be used to
identify the FDMA.

Elevate the flap from the dorsal aspect at the base of the index finger. It
can be extended to the PIP joint distally (14,31,38,39). If additional width
of the flap is needed, expand it toward the third metacarpal to avoid a first
web space contracture.

Expose the FDMA distally to proximally and raise the aponeurosis with the
perivascular fat as a pedicle (Fig. 38.14). The artery is usually superficial
to the fascia, and a branch of the superficial radial nerve is included in the
pedicle.

Take care to stay superficial to the extensor tendon paratenon. Rotate the
proximally based flap around the point of origin of the artery at the base of
the first interosseous space. During the dissection, there is often a large
perforator near the second metacarpal neck that must be ligated.

Once the pedicle is raised, tunnel it subcutaneously to the thumb without

kinking. The flap can be used to cover thumb defects, either palmarly or
dorsally, and can reach from the proximal portion of the thumb almost to
its tip.

CONCLUSIONS
Our approach to fingertip injuries is the following: for adults, we assess the
injury-related factors as well as patient-related factors such as age, occupation,
general medical health, hand dominance, compliance, and associated injuries
(Table 38.1). For small defects (less than 8 mm) with no exposed bone, we prefer
to let these injuries heal by secondary intention. We have found that the
cosmesis and sensitivity are adequate. If the defect is larger or has exposed
bone, then we try to use a local flap. The flap required is dependent on the
angulation of injury. For transverse or dorsal oblique injuries, we prefer a local V-Y
advancement. We also use a lateral V-Y advancement for transverse defects. If
the defect is oriented volarly, we perform a cross-finger flap or a thenar flap.
Both require patient compliance, a second surgical procedure, and postoperative
rehabilitation. For larger defects, we consider distant flaps and revision
amputation. If there is a minimal portion of the nail bed remaining or no bone to
support the nail bed, than a revision amputation is performed with ablation of
the nail germinal matrix.

We consider thumb injuries as a separate category. For volar injuries, we prefer

the Moberg advancement flap. For larger defects, we use a first dorsal
metacarpal or a cross finger flap.
For children younger than 3 years of age, we replace the amputated portion as a
composite graft. In the 3- to 8-year-old age group, we defat the amputated part
and use it as a free skin graft. Patients older than 8 years of age are treated as
adults (Table 38.2).

We agree with Louis (25), who believes that the deficit in sensitivity,
hypesthesias, dysesthias, and cold intolerance in distal tip amputations may be
primarily related to the injury and not to the treatment.
NAIL BED INJURIES
The anatomy of the fingernail is highly specialized. It has four components: the
nail plate, the nail bed, the perinail soft tissues, and the underlying bone and
ligamentous support. The nail has multiple functions, including supporting and
protecting the fingertip. It also plays a role in sensation of the digit in that if the
nail is lost two-point discrimination of the finger decreases (45). Nail growth is
dependent on several factors including age of the patient, injury pattern, and
seasonal changes. On average, growth is approximately 0.1 mm per day. After
loss of a nail, it takes approximately 3 to 6 months for a new nail to grow in
completely, and nail growth is not normal for the first 100 days (5).
Optimal treatment of a nail bed injury requires an understanding of the anatomy
and physiology of its components (Fig. 38.15). The nail fold is the most proximal
portion of the nail complex. It consists of two parts, which include the dorsal roof
and germinal matrix. The dorsal roof of the nail fold forms the cells that
contribute to the shine of the dorsal nail surface. The nail bed also consists of
two components. The most proximal portion is the germinal matrix. It is located
along the proximal ventral floor of the nail fold and extends to the lunula. This is
the area of the nail bed epithelium where nail plate production begins, and it is
critical to nail growth (Fig. 38.16). The sterile matrix is the distal portion of the
nail bed and extends from the lunula to the hyponychium. The sterile matrix acts
as a road map for growth of the advancing nail and functions to keep the nail
adherent to the underlying epithelium (Fig. 38.17). The eponychium is the distal
portion of the nail fold that attaches to the dorsal surface of the nail. The lunula
is the white arc just distal to the eponychium that parallels the natural distal
shape of the nail. Distally, the hyponychium is the area of junction of the nail bed
and the fingertip skin. It functions as a protective barrier and prevents bacteria
from migrating beneath the nail.

Both Zook et al. and Guy have reviewed the etiology of nail bed injuries and had
very similar findings. The majority of these injuries occurred from a closing door,
a machine injury, a saw injury, or by being crushed between two objects (Table
38.3) (16,48).

The initial treatment of the injured nail bed is of utmost importance to prevent a
nail deformity. Treatment of a nail deformity often requires a reconstructive
procedure that is technically demanding, and the results are typically less than
optimal. One problem facing the surgeon evaluating the injured nail is obscured
visualization due to a subungual hematoma. In general, subungual hematomas
encompassing greater than 50% of the nail have a higher likelihood of being
associated with a displaced nail bed injury. In this situation, one should consider
removing the nail and exploring the nail bed. Injuries with a subungual
hematoma of less than 50% of the nail are less likely to have a repairable nail
bed injury and should be treated nonoperatively. Patients may experience pain
from the pressure related to a subungual hematoma. Making a small hole in the
nail with a microophthalmic cautery can relieve the pressure. Drain the
hematoma while taking care to not injure the underlying nail bed.
CLASSIFICATION OF NAIL BED INJURIES
Injuries of the nail bed can be divided into those that involve the germinal matrix
or sterile matrix. In general germinal matrix injuries are more serious. Nail
formation starts and is predominantly from the germinal matrix; therefore an
injury in this region has a higher likelihood of permanently affecting nail growth.
Van Beek et al. have further classified acute fingernail injuries, as outlined below
(42).
Germinal Matrix Injury:
GI: Small subungual hematoma proximal nail (25%)
GII: Germinal matrix laceration, large subungual hematoma (50%)
GIII: Germinal matrix laceration and fracture
GIV: Germinal matrix fragmentation
GV: Germinal matrix avulsion
Sterile Matrix Injury:
SI: Small nail hematoma (50%)
SII: Sterile matrix laceration, large subungual hematoma (50%)

SIII: Sterile matrix laceration with tuft fracture

SIV: Sterile matrix fragmentation
SV: Sterile matrix avulsion
This classification system provides a framework for determining the appropriate
treatment regimen (Table 38.4). Obtain radiographs to evaluate for a displaced
distal phalanx fracture. Treat grade I injuries nonoperatively unless they are
painful, for which decompression or nail removal can be performed.

Repair of Grade II, III, and IV Injuries

Treat grade II, III, and IV injuries by first carefully removing the nail. An
adherent nail may indicate a grade I injury with limited nail bed
involvement.

Facilitate nail removal with a freer elevator by exploiting the plane

between the nail and the nail bed. Be careful when removing the nail so as
not to injure the nail bed.

Clean the nail and debride the nail bed if necessary. There is little
advancement possible of the nail bed, so limit debridement to
contaminated or devitalized tissues.

Repair the nail bed under loupe magnification using 6-0 or 7-0 chromic
suture.

If the proximal germinal matrix is injured, visualization may be obscured

by the nail fold. Make skin incisions at 90 to the nail fold along the
lateral border of the nail. Then elevate the nail fold to evaluate the extent
of injury fully.

Most distal phalanx fractures are treated with a splint. A displaced fracture
may cause displacement of the nail bed, and occasionally Kirschner wire
fixation is required.

After repair, replace the nail beneath the nail fold. Replacement of the nail
has several important functions: (a) it serves as a template for the new

growing nail; (b) it serves as a splint for fractures, (c) it provides a biologic
dressing for the nail bed, and (d) it prevents scarring of the nail fold to the
nail bed.

Suture the nail in place with 4-0 or 5-0 nylon sutures. Place two horizontal
mattress sutures proximally both radially and ulnarly to prevent injury to
the germinal matrix. One or two simple sutures may be placed in the distal
aspect of the nail and pulp to further secure the nail.

If the nail is fragmented or not available, an artificial nail, Silastic sheet, or

nonadherent gauze can be used.

Bandage the finger to protect the digit and restrict motion for 7 to 10
days. Leave the replaced nail in place for 2 weeks.

NAIL BED AVULSIONS

The nail bed can avulse from either the germinal or sterile matrix. Similar to nail
bed lacerations, the majority of avulsions occur in the distal aspect of the sterile
matrix. Nail bed avulsions account for approximately 15% of all traumatic injuries
to the nail (36). If the nail bed is allowed to heal by granulation, the resultant
scar may cause a nail deformity or nonadherence.
Avulsed Segment
Ideally, the avulsed nail bed is sutured in an anatomic position (36). Often, the
nail bed is attached to the nail plate. A decision must be made whether to
separate the nail bed from the nail plate or suture the nail bed and plate as one
unit. If the pieces are small, we tend to suture the nail bed and plate as one
segment. If the fragment of the avulsed nail bed is large, it is carefully separated
from the nail plate (Fig. 38.18). The nail bed can be sutured directly onto bone,
as outlined by both Zook and Shepard (36,47).

Many times, inspection in these situations reveals that the nail matrix is
still attached to the avulsed nail plate. If the segment of nail matrix is
large, shave it away for use as a free graft (Fig. 38.18B).

Properly align the avulsed segment and suture it to the defect with 6-0 or
7-0 chromic suture.

Replace the avulsed nail to cover the defect (Fig. 38.18D). If the nail plate
is badly damaged, the dressing should be fine mesh gauze or other nail
substitute.

Use half-buried horizontal mattress sutures in conjunction with nail roof

elevation to anchor a displaced nail plate or nail bed, or both, into the
proximal nail fold (Fig. 38.19).

The skin remnants can be sewn to the surrounding skin with 6-0 nylon
suture.

Incomplete Avulsions
Incomplete avulsion of the nail bed often occurs at the germinal matrix. A
bending force through the distal phalanx is transmitted proximally to avulse the
germinal matrix and displace the nail from beneath the nail fold. In the past, the
distal nail was left in place and the proximal avulsed nail bed was
reapproximated (34). At present, elevation of the entire nail to ascertain the
degree of injury and repair is recommended (Fig. 38.19) (36).
If the avulsed segment of nail bed is not available or amenable for repair,
alternative treatment methods are necessary. In the past, treatment involved
split-thickness skin grafts, dermal grafts, and healing by secondary intention.
Zook and Shepard have used split-thickness nail bed grafts with good success
(37,47). The preferred donor site is the injured nail, although grafts have been
described from the great or second toe. Full-thickness grafts are discouraged due
to the associated donor site morbidity.

Harvest a split-thickness graft from adjacent tissue for coverage. A splitthickness nail matrix graft from a great toe can be used if insufficient
tissue is presented on the digit of the avulsion.

When taking a split-thickness nail graft, keep in mind that the thickness of
the nail sterile matrix is only 240 to 990 m (30 to 40 thousandths of an
inch) and that the grafts are 165 to 240 m (7 to 11 thousandths of an
inch) (Fig. 38.20). Use a microscope to facilitate harvesting the graft.

Create a template of the defect with a rubber glove and outline on the
donor tissue. The tip of the scalpel should be seen at all times when
harvesting the graft. Not visualizing the tip of the blade will likely lead to a
graft that is too thick.

Once the graft is procured, sew it into the defect with 7-0 chromic suture
(Fig. 38-21). A linear avulsion may be treated with a bipedicle graft as an
alternative. This technique fills the defect by advancing the nail bed from
either side.

The ideal dressing is the removed nail plate covered with a firm dressing.

NAIL RECONSTRUCTION
Nail bed injuries can lead to a variety of nail abnormalities. Typical deformities
include nonadherence, split nails, linear ridging, crooked nails, and hooked nails.
Nonadherence after trauma is the most common nail deformity. Distal
nonadherence can be problematic due to dirt becoming lodged underneath the
nail. Proximal nonadherence is more troublesome because the nail can become
unstable and tear loose when picking up small objects. Nonadherence occurs
when the nail does not adhere to the abnormal scar that has formed within the
injured nail bed. Scar excision and primary repair has been performed. Although

Zook and Russell believe that primary closure of the nail bed leads to excessive
tension with resultant increased scar, they have recommended split-thickness
nail grafting (20,37,47).

SPLIT NAIL
Split nails occur because of a longitudinal scar in the germinal or sterile matrix.
The nail, therefore, grows on either side of the scar in the germinal matrix. The
scar in the sterile matrix leads to nonadherence, and increased stresses in the
nail causes the split or crack. Reconstructing a split nail is similar in principle to
treating nonadherence. If the split is in the sterile matrix or distal germinal
matrix region, the scar is excised and replaced with a split-thickness matrix graft.
A split nail due to an abnormality in the germinal matrix requires a germinal
matrix graft, which can be harvested from another finger or toe. Both have the
complications of persistent deformity and donor site morbidity (Fig. 38-22).

LINEAR RIDGING
Linear ridging is often secondary to a bony protuberance beneath the nail bed.
As described by Kleinert, the treatment in this setting involves incising the nail
bed over the involved area (20). An ostectomy is performed, and the nail bed
reapproximated. Shepard has reported good results in six patients with this
technique (Fig. 38.23) (37). If the etiology is due to scar from an injury to the
sterile matrix, one can excise the scar and replace it with a split-thickness nail
bed graft. For defects in the germinal matrix, one may be forced to use a fullthickness graft with its associated donor site complications. Linear ridging may
be related to compression of the germinal matrix from a mucous cyst arising
from the DIP. These cysts often arise in association with an osteophyte of the DIP
related to degenerative joint disease. The deformity may progress from ridging

to a split nail. Aspiration of the cyst often leads to recurrence. The surgical
management involves excision of the osteophyte and cyst, including the stalk
from the DIP. Gingrass et al. have reported a low rate of cyst recurrence with this
technique (15). Progression of the nail deformity is prevented, but the deformity
is likely to persist.

LATERAL DEVIATION
Lateral deviation of the nail is due to a full-thickness avulsion of the lateral
aspect of the nail bed with displacement (20). Rather than rotating a portion of
the nail bed into the defect, the recommended management involves elevation
of the entire nail bed and placing it in a straight position (Fig. 38.24).

After removal of the nail plate, create a full-thickness flap of sterile and
germinal matrix down to the bone, with the only attachment being the
proximal portion of the germinal matrix.

Excise the epidermis between the nail bed and nail fold in the direction of
rotation of the flap.

Rotate the flap into the correct longitudinal position.

Suture the wedge excision primarily, creating a straight nail.

HOOKED NAIL
A hooked nail involves volar displacement of the distal aspect of the nail. It can
be due to a malunited fracture or a deficiency of skin of the digital pulp. Atasoy
et al. have described an antenna procedure for correcting the deformit y
(Fig. 38-25) (4). The procedure involves freeing the tethered pulp and nail bed,
splinting the freed nail bed, and reconstructing the soft-tissue defect of the pulp.

Elevate the curved nail plate from the nail bed along its length and discard
the portion of the nail plate distal to the lunula.

Incise the pulp skin along the hyponychium and extend it on both sides of
the pulp. Deepen the incision to reflect the pulp skin in a normal contour.
Elevate the full-thickness nail bed to the level where the nail bed is
straight.

Insert two or three 0.028 Kirschner wires into the distal phalanx to splint
the nail bed.

Cover the pulp defect with a cross-finger flap. Shepard has recommended
reconstructing the pulp defect with a lateral V-Y advancement flap and
skin graft rather than a cross-finger flap (37). Bone grafting of the elevated
portion of the distal phalanx has been discouraged by Zook due to the
likelihood of bone graft resorption (46).

An alternative treatment method involves shortening the nail bed, thereby

allowing the nail to be supported by bone. A hook nail may be prevented
while treating the initial injury by shortening the nail bed 2 mm greater
than the distal phalanx (21). Both procedures are simple solutions but
leave one with a shortened nail.

TOTAL NAIL LOSS

Total nail loss can be treated by split-thickness skin grafting, nail prosthesis, or
total nail reconstruction. Total nail reconstruction involves transfer of the nail bed
as a free or vascularized nail graft. The free graft can be taken by elevating the
nail plate and harvesting the nail bed and matrix as far as the proximal end of
the nail matrix (29,33). In free nail grafts, Shepard notes the importance of
taking the proximal nail fold. All patients in his series in which this was not
incorporated would have failed. When the proximal nail fold was incorporated, he
had a 50% success rate (37). The lateral edge of the great toe is often the donor
site. The donor site is covered with a split-thickness skin graft.
Vascularized nail flaps have also been described. These flaps transfer a free nail
with the advantage of better biologic adherence and viability. They are
technically more difficult and take much longer to perform (12). Three types of
vascularized grafts have been described. The first type is a long pedicle
vascularized nail flap. This flap entails an 11 cm incision in which the digital
artery and vein are used for anastomosis. A venous flap allows for a shorter
incision, with the venous anastomosis proximal to the interphalangeal joint. The
disadvantage of this flap is the concern of the existence of venous valves. The
last flap is the short pedicle vascularized nail flap, which represents a
combination of the above two flaps.
AUTHORS' PERSPECTIVE
Nail bed injuries represent a very common injury in which the severity is often
overlooked. It is imperative that these injuries be treated accurately initially to
prevent a nail deformity. Nail bed injuries should be repaired anatomically and
may require fixation of a displaced distal phalanx fracture. If it is available, the
nail or substitute is replaced beneath the nail fold. Limiting a nail deformity may
preclude the need for one of the technically demanding reconstructive
procedures.