- See:
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Amputations of the Fingers and Hand:
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Crossed Finger Flap:
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Distal Phalangeal Fractures
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Nail Bed Injuries
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Paronychia:
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Moberg Flap
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Phalangeal Injury - Menu
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Soft Tissue Replacement in the Hand and Forearm:
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Thumb Defects:
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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;
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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;
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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.
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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;
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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;
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full thickness grafts
- are thicker, contract less and therefore do not distort the nail bed;
- however, they are bulkier and are less predictable;
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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%;
- references: Composite Graft Replacement of Digital Tips. A study in children. NS Moienem and D Elliot. J. Hand Surg. 22-B. 3. 346-352. 1997.
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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.
Achauer-BM.
Welk-RA. 1992 Year Book of Hand Surgery. Article 4-11. Original Article: Plast Reconstr Surg. 1990. 85. pp 937-941.
