- 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:
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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 Jun Arata et al, the authors used this method in 16 cases in which a digit other
than the thumb had been amputated between the 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 the 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. Achauer-BM.
Welk-RA. 1992 Plast Reconstr Surg. 1990. 85. pp 937-941.
The Hueston flap in reconstruction of fingertip skin loss: results in a series of 41 patients.
Island Flaps of the Hand.
JM Markley.
Hand Clinics. Vol 1(4). p 689-700. 1985.
Fingertip reconstruction.
The Kutler method of repair of finger tip amputations.
RH Fisher.
JBJS 49-A. p 317-322. 1967.
The thenar flap - an analysis of its use in 150 cases.
CP Melone et al.
J. Hand Surg. Vol 7. p 291-297. 1982.
Fingertip reconstruction with flaps and nail bed grafts.
RE Brown et al
J. Hand Surg. Vol 24-A. 1999. p 345-351.
The palmar pocket method: An adjunct to the management of zone I and II fingertip amputations. Jun Arata, MD JHS-Am Sep 2001 Vol 26 No 5
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.
