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Duke Orthopaedics
presents
Wheeless' Textbook of Orthopaedics

Finger Tip Injuries


- See:
      - Phalangeal Injury - Menu
      - Thumb Defects:
             - Moberg Flap
 

- Nail Bed Injuries:
         - if injury damages the distal phalanx, particularly when the damage extends into germinal matrix, the nail will probably be irregular and 
                painful when it grows back;


Fingertip Amputation Without Bone Exposure:


- Fingertip Amputation With Bone Exposure:
    - see: amputations of the fingers and hand:
    - exposed bone is not satisfactory bed for skin graft unless area of exposure is 5 mm or less;
           - when such injuries heal by secondary intention, skin over end of bone may be just scar of very poor quality & easily broken down w/ pressure,
                     resulting in chronic ulcer;
    - bony prominences must be reduced, & amputation stumps should be rounded off to avoid spikes of bone sticking up & causing future pressure necrosis;
           - failure to eliminate spikes will often result in a prominence that just keeps enlarging and must be excised secondarily in the future;
    - in certain circumstances, small viable flaps of tissue may be present within amputation wound, & these
           can be used to cover exposed bone with the remaining defect covered by skin graft;

    - hazards: in the fingers (as opposed to the thumb), the dorsal vascular anatomy is dependent on
           the proper digital vessels, and therefore Moberg type flaps should not be used in the digits;
    - V-Y local advancement flaps:
    - crossed finger flap:
    - thenar flap:
    - revision amputation and shortening of digit:
           - indications: loss of over 50% of the distal phalanx or irreparabel damage to the nail matrix
           - advantages: one stage procedure which allows early mobilization and desensitization (which is important in older or stiffer hands);
           - protruding bone should be trimmed to the level of the remaining nail bed;
                  - avoid more proximal bone debridement to avoid hook nail (trim bone to achieve tension free closure);
           - always trim nail bed as far as proximal as bone;
                  - when there is less then 5 mm of sterile matrix, nail adherence will be losed and therefore nail bed should be ablated;
           - insertions of flexor and extensor tendons on most proximal portion of the distal phalanx should be left intact if possible;
           - careful handling of the nerve ends is important to avoid neuroma;
           - tension free closure is essential;


- Amputations of the Fingers and Hand:
      - soft tissue replacement in the hand and forearm:
      - replantation of digits:
      - palmar pocket method:
               - technique of replantation without anastomosis;
               - in the report by Arata J, et al, the authors used this method in 16 cases in which a digit other than the thumb had been amputated between tip and lunula;
                       - in 13 cases the method was completely successful, and in 3 cases there was a small area of tip necrosis;
                       - palmar pocket method is a simple and reliable operation for fingertip reattachment and more comfortable for patients than pocketing in chest wall or abdominal wall;
                       - technique:
                              - the amputated part is cleansed and washed in normal saline and the nail was removed;
                              - amputated parts were reattached and fractured bone segments were fixed with K wires, which were then cut short;  
                              - the amputated part was then de-epithelialized down to the mid-dermal layer, using a scapel;
                              - a 2 cm incision is made in the mid-palm, and a subcutaneous layer is created;
                              - the amputated part is then inserted into the pocket;
                              - the skin proximal to the amputation site is then sutured to the palm;
                              - at 20 days, the sutures are removed and the digit is careful removed;
                              - moist dressings are applied on a daily basis until epitheliazation is complete



Treatment of subungual hematomas with nail trephination: a prospective study.

Nonoperative management of fingertip pulp amputation by occlusive dressings.

Vascular anatomy of the finger dorsum and a new idea for coverage of the finger pulp defect that restores sensation.

The proximal inset thenar flap for fingertip reconstruction.

Year Book: One-Stage Reconstruction of the Postburn Nailfold Contracture

The Hueston flap in reconstruction of fingertip skin loss: results in a series of 41 patients.

Island Flaps of the Hand

Fingertip reconstruction.

The Kutler method of repair of finger tip amputations.  

The thenar flap - an analysis of its use in 150 cases.  

Fingertip reconstruction with flaps and nail bed grafts.  

The palmar pocket method: an adjunct to the management of zone I and II fingertip amputations

Factors affecting composite graft survival in digital tip amputations.

Replantation of fingertip amputation by using the pocket principle in adults.

Fingertip Injuries: Evaluation and Treatment.

Composite Grafting for Traumatic Fingertip Amputation in Adults: Technique Reinforcement and Experience in 31 Digits



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, May 14, 2012 12:17 pm