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Duke Orthopaedics
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Wheeless' Textbook of Orthopaedics

Finger Tip Injuries



- See:
      - Amputations of the Fingers and Hand:
      - Crossed Finger Flap:
      - Distal Phalangeal Fractures
      - Nail Bed Injuries
      - Paronychia:
      - Moberg Flap
      - Phalangeal Injury - Menu
      - Soft Tissue Replacement in the Hand and Forearm:
      - Thumb Defects:
      - V-Y Local Advancement Flaps:


- Soft Tissue Loss Without Bone Exposed:
    - fingertip lacerations, or avulsion of substance, as long as bone is not exposed, can generally heal by combination of wound contraction 
          and epithelialization, resulting in very little scarring;
          - this method of rx is often desirable because contraction of wound edges pulls normal, well innervated skin in toward the center of defect;
    - dressing changes / open methods of treatment:
          - w/ soft tissue loss of less than 1 sq cm, consider dressing changes;
          - healing by wound contraction and epithelialization (healing takes upto 2 months);
          - indications and advantages: children, adults with defects < 1 cm or less, simple procedure;
          - by iniating early motion, edema and pain will be diminished;
    - FTSG taken from hypothenar eminence: indicated for wounds larger than 1 sq. cm;
    - references: Nonoperative management of fingertip pulp amputation by occlusive dressings.


- Amputation Without Bone Exposure:
    - w/ minimal loss of soft tissue of distal finger tip, good results can be found w/ dressing changes and wound contraction, causing most of 
           end of digit to be covered satisfactorily;
    - references: Nonoperative management of fingertip pulp amputation by occlusive dressings.
    - skin grafts:
           - amputation of distal pulp in plane of subQ tissue, healthy vascularized bed exists which is ideal for coverage by a free skin graft;
           - either STSG or full thickness skin graft can be used, and both types will develop some degree of innervation over many months;
    - STSG:
           - STSG has higher % of take & contracts to draw in normal sensible tissue (contraction may distort the nail bed);
           - indications: no bone exposed, sites with less contact;
           - advantages: graft shrinkage reduces size of the defect;
           - technique:
                  - prepare the recipient site
                  - choice of donor site (side of proximal phalanx or hypothenar eminence)
                  - always consider donor site scarring as well as color and texture match;
    - full thickness grafts
           - are thicker, contract less and therefore do not distort the nail bed;
           - however, they are bulkier and are less predictable;
    - composite grafts:
           - composite flaps refer to the replacement of non vascularized amputated finger tips (which may or may not be defatted);
           - note that composite grafts from the amputated finger tip (which are defatted and opposed to the wound) have a high rate of failure in adults but may be indicated in children;
           - in the study by Moiemen and Elliot, 11/18 composite flaps which were replaced w/ in 5 hours survived, while 0/32 composite flaps survived that were replaced after 5 hours;
                  - complete graft take occured in 22% of digits, and partial graft take occured in 52%;
                        - in many cases, more graft was viable after several months, than had originally been expected;
                  - total graft failure occured in 26%;
                  - reference: Composite Graft Replacement of Digital Tips. 2. A study in children
    - amputation and shortening of digit:
           - protruding bone should be trimmed to the level of the remaining nail bed (avoid more proximal bone debridement to avoid hook nail);
           - 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



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.

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



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

Last updated by Data Trace Staff on Monday, May 14, 2012 12:21 pm