FINGER TIP INJURY

Definition

Injuries to the fingertip area which are

distal
to the insertion of the flexor & extensor
tendons
tendons

Introduction
Most 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 intention

Skin grafting
Shortening of the bone & primary closure
Local & regional flap
Composite reattachment
Microsurgical replantation (very rare)

Anatomy of Fingertip

Anatomy of Fingertip

Mechanism of Injury
Mechanism of
injury:
crushing
clean amputation

Also:
mixed mechanism of injury.

Classification
Classification of Allen for Amputations of the
Fingertip
Type
Anatomic Site for Amputation
I

distal to fingernail tip

II

distal to tip of distal phalanx

(involves distalmost nail bed)

III

distal to mid-distal phalanx

IV

distal to distal PIP joint (entire

distal phalanx)

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

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 injury
Age
Gender
Handedness
Occupation
Avocation
History of previous hand problem & systemic
disease

General Principles of
Evaluation & Treatment
Which finger??
Complete hand examination

Skin
Vascularity
Neurologic function
Flexor & 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 & Treatment

Any 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 Principles

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

Soft Tissue Loss

Without Exposed Bone
Appropriate treatment:
Skin graft
Healing by secondary intention

Still controversy

Soft Tissue Loss

Without Exposed Bone
Smaller 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 Bone
Larger wounds if conservative: not durable, so
consider skin graft
Should be full-thickness:

Contract less
More durable
Less tender
Better sensibility

Taken from ulnar border of the hand (glabrous skin)

Width: up to 2 cm
After 7 days start ROM exercise
Should not be used indiscriminately

Soft Tissue Loss

With Exposed Bone
Satisfactory 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 flap
Regional flap

Soft Tissue Loss

With Exposed Bone
Based on:
Level & angle of
amputation
Age
sex

Revision Amputation
Indication:
When not enough sterile matrix remain (< 5 mm)
Advanced age
Systemic condition

Remaining nail matrix ablated

If flexor & extensor tendons insertion cant
be preserved disarticulation

Revision Amputation
Tendons 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 Flaps
Advantages:

Can be used for any age

Preserve length
Do not requires skin graft
Similar quality, texture & colour
Early ROM

Requires judgement & expertise

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

Most appropriate for distal transverse amputation
Dual triangular flap from the lateral side
Without undermining
Disadvantages:
small & difficult
to advance
Flap necrosis
Nail deformity
Hipersensitivity

Regional Flaps
Most commonly used:
Cross-finger flap
Thenar flap

Preserve length
Volar oblique angle
Too proximal amputation
More than 1 finger combination

Regional Flaps
Disadvantages:
2-stage procedure
Prolonged 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 arthritis
Systemic condition: RA, DM, vasospastic disorders

Regional Flaps
Post-op:

Bulky dressing
Splint
Uninjured finger left free
Flap division 12-14 days after
Suturing recipient cut edge: not
recommended
Aggressive ROM program

Cross-finger Flap
Hinge 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 Flap
Can be used for any finger, but small finger difficult
Disadvantages:
PIP stiffness
Tenderness over donor-site

Location: high on thenar eminence

Radial border parallel & adjacent to MCP crest
Proximally based

Thenar Flap
As 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 Thumb

Similar to other digits
Importance of length preservation &
restoration of sensibility magnified
Choices:

Moberg Flap
Cross-finger Flap
Kite Flap
Littler 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 ArteryIsland Pedicle Flap (Kite Flap)

1 stage
Include
neurovascular
bundle
Based on 1st dorsal
MC Artery
Donor: FTSG