Finger tip injuries
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Finger tip injuries
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Finger tip injuries
- 2. Introduction • Fingertip injury is any soft tissue, nail or bony injury distal to insertion of the long flexor and extensor tendon of a finger or thumb. • Acute fingertip and thumb injuries are common and require prompt and meticulous composite soft tissue repair in incomplete amputations.
- 3. Epidemiology • Can affect all ages but common in working class adults and children. • In adults – Laceration (Most common) – Crush & Avulsion injuries • In children – Most injuries arise at home and due to jamming/crushing by doors
- 4. Clinical Presentation • History – Mechanism: • Avulsion • Laceration • Crush – Hand dominance – Occupation & Hobbies – Time since injury – Tetanus immunization status
- 5. Clinical Presentation • Physical Examination – Inspection • Crush vs Sharp injury • Presence or absence of exposed bone • Red line sign • Ribbon sign • Nail or Nail bed involvement • Viability of tip • Presence of foreign body – Range of motion • Flexor and Extensor tendon involvement
- 6. Clinical Presentation • Imaging – AP & Lateral Radiograph to assess the bony involvement.
- 7. Allens Classification Type Feature Type I Involving pulp only Type II Pulp & Nail bed Type III Distal phalanx fracture with pulp & nail bed Type IV Lanula, Distal phalanx fr, Pulp & Nail bed
- 8. Classification Zone Characterstics Zone I Distal to distal phalanx Nail bed & matrix preserved Zone II Distal to lunula of nail bed Distal phalanx exposed Zone III Nail matrix involved Loss of entire nail bed Reference : Treatment of fingertip and nail bed injury Rosenthal EA Orthop Clin North Am 1983 Oct; 14(4):675-97
- 9. Classification - PNB • Evan & Bernadis (2000) • Too complex for daily clinical use
- 10. Objective of Repair • To restore – Sensibility – Function – Survial – Adequate length
- 11. Principle of Finger Amputation 1. Volar Skin flap should be long enough to cover the volar surface and tip of osseous structure and join dorsal flap without tension 2. End of digital nerve dissected carefully and resected 6mm proximal to soft tissue flap to prevent painful neuroma 3. Flexor and extensor tendon should be drawn distally, divided and allowed to retract proximally. 4. When amputation through joint the osseous condyle should be contoured to avoid clubbing 5. Before wound closure tourniquet should be released and vessel cauterized.
- 12. Management • Non Operative – Healing by secondary intention (<1 cm skin loss with no bone & exposed tendon) Ref : Indian J Orthop. 2007 Apr-Jun;41(2) 163-168 • Operative – Primary closure (Revision amputation) – Full thickness skin grafting – Flap Reconstruction
- 13. Healing by Secondary Intention • Initial treatment with irrigation and soft dressing • After 7-10 days, soak in water peroxide solution daily followed by application of soft dressing and fingertip protector • Complete healing : 3-5 weeks
- 14. Revision Amputation • Remove remaining nail matrix to prevent irritant nail remnant • If flexor or extensor tendon insertion cannot be preserved, disarticulate DIP joint • Cut digital nerve & remaining tendon as proximal as possible • Palmar skin brought over bone and sutured to dorsal skin
- 15. Flap Reconstruction Techniques Site Technique 1. Finger Tip Straight/Dorsal Oblique Laceration •V-Y advancement flap •Digital island artery Volar Oblique Laceration •Cross finger flap (age>30 yrs) •Thenar flap (age<30 yrs) 2. Volar Proximal Finger Cross finger (Age>30 yrs) Axial flag flap from long finger 3. Dorsal Proximal Finger & MCP Reverse Cross Finger Axial flap from long finger 4. Volar Thumb Moberg Advancement Volar Flap (<2cm) FDMA (if >2cm) Neurovascular Island Flap (upto 4 cm) 5. Dorsal Thumb FDMA 6. First Web Space Z plasty with 60 degree flaps Posterior Interosseous Fasciocutaneuos flap 7. Dorsal Hand Groin Flap
- 17. Cap Technique Indication •Good quality skin with sterile matrix Procedure •Composite tissue reattached
- 18. Kutler V-Y Advancement Flap Indication • Pulp compromised • Lateral hyponychial skin uninjured
- 19. Atasoy V-Y Advancement Flap Indication • Transverse/Dorsal oblique cut
- 20. Reverse Digital Artery Island Flap Indication • To cover dorsal & volar defect distally
- 21. Adipofascial Turnover Flap Indication • To cover distal dorsal defect 3 cm in length
- 22. Dorsal Pedicle Flap Indication • Amputation proximal to the nail bed • preserving length is essential • Attaching to other finger is undesirable
- 24. Thenar Flap Indication • Middle & Ring Finger Coverage