Open treatment of fingertip injuries in adults

Hook nail deformity

Hook-nail deformity is frequently seen after a fingertip amputation, whether or not flap reconstruction has been done. It is more frequent if the bony support is missing. The deformity results in esthetic and functional impairment which can lead to complete finger amputation. Correction is surgical, but is difficult and surgical series are small. Soft-tissue flap augmentation is simple, but does not add a bony support. Bone augmentation using local flaps is limited by the small size of the distal phalanx remnant. Toe transfer is more logical but, as it is a highly demanding technique, only a few cases have been published. The present study sought to review all the published techniques and their results, to help the reader choose the one best suited to their patient.

Management of Fingertip Injuries: A Survey of Opinions of Surgeons Worldwide

Introduction Fingertip injuries are common injuries in all ages. There is currently no consensus nor evidence to support the use of any one treatment, with numerous options available for management. The aim is to review the consensus for treatment of fingertip injuries among surgeons worldwide.

Materials and Methods Nonprobability judgment sampling using purposive method was performed on surgeons (n = 65) using two digital platforms of the community of practice of hand surgeons. Three illustrative case scenarios were presented to the participants to understand their consensus on treating fingertip injuries, and their choice of treatment for themselves with a similar injury.

Results This survey demonstrates that there is a wide range of treatment preferences for fingertip injuries for each clinical scenario. In Allen 1 and in crush injuries, most respondents favored healing by secondary intention (66.2 and 92.3%, respectively). In Allen 3 injuries, 72.3% favored surgical intervention. In all clinical scenarios, most surgeons would want their own fingertip injuries treated identically to how they would treat patients with similar fingertip injuries (93.9, 96.9, and 95.4%, respectively). Furthermore, our study demonstrated experience in surgery was not associated with treatment preferences.

Conclusion Management of fingertip injuries remains controversial, but this study is suggestive that treatment preferences may not be determinant on patient factors, given that all of our respondents are highly functioning individuals who practice microsurgery, but most chose to administer the same treatment to patients as they would to themselves.

Management of partial fingertip amputation in adults: Operative and non operative treatment

BACKGROUND

Hand and finger injuries account for approximately 4.8 million visits to emergency departments each year. These injuries can cause a great deal of distress for both patients and providers and are often initially encountered in urgent care clinics, community hospitals, and level one trauma centers. Tip amputation injuries vary widely in mechanism, ranging from sharp lacerations to crush injuries that present with varying degrees of contamination. The severity of damage to soft tissue, bone, arteries and nerves is dependent upon the mechanism and guides treatment decision-making. The management algorithm can oftentimes be complex, as a wide variety of providers, including orthopedists, general surgeons, plastic surgeons and emergency physicians, may care for these injuries, depending on location and local culture. We review the common mechanisms for tip amputation and the optimal treatment in adults, based on the severity of the injury, degree of wound contamination, and the facilities available to the provider.

METHODS

Pubmed was searched using text words for articles related to management of fingertip injuries in adults. Bibliographies of matching articles were searched for additional relevant articles, which were then also reviewed. 107 articles were reviewed in total, and 61 were deemed relevant for inclusion. All clinical studies and reviews were included. Particular attention was paid to articles published within the past 15 years.

RESULTS

In the United States, up to 90% of fingertip amputations are treated with non-replant techniques. In comparison, the majority of amputations in Asian countries are replanted due to moral values and importance of body integrity. Tip amputation injuries can be managed with local debridement, complex reconstruction, or simply with irrigation and application of a sterile dressing.

CONCLUSION

In the United States, most fingertip amputations in adults are treated with non-replant techniques. However, the precise management of a fingertip injury in adults depends on the degree of injury itself, and a number of operative and non-operative techniques may be successfully employed.

IFSSH scientific committee on skin coverage: 2015 report

Skin coverage in hand reconstruction is a challenging and vast chapter in hand surgery; covering every aspect of it in a report is simply not feasible. Therefore, this report focuses on a few specific topics. The coverage of anatomical regions like the fingertips is common ground for hand surgeons worldwide, but in the last 10 years, various refinements have been published in order to optimize the reconstruction of this organ. Nevertheless, in many emergency departments, the amputation of badly injured fingertips, including the thumb, remains the preferred treatment. The main focus of this report is to counter this tendency by providing alternatives to surgeons. Large defects in the fingers involving more than one segment, defects in the palm and in the dorsum of the hand are currently debated in international meetings. The use of skin substitutes vs. the use of extremely refined microsurgical procedures vs. classic island flaps has generated animated discussions, which are also influenced by cultural and socioeconomic factors around the world. This report offers the views of six surgeons from four different countries, in the hope of animating discussions and suggesting new approaches.

Management of complications relating to finger amputation and replantation

There are many options in the management of fingertip or finger amputations. Injudicious revision amputation may cause complications. These complications can be prevented by tension-free closure of the amputation stump or primary coverage with appropriate flap. Replantation is the best way to keep the original length and maintain digital function. Patent vein repair or venous drainage with bleeding until neovascularization to the replanted part is the key to successful replantation. Prevention and management of complications in replantation and revision amputation increase patients' satisfaction and decrease costs. Research is needed to define new indications of replantation for digital amputation.

Pediatric thenar flaps: a modified design, case series and review of the literature

BACKGROUND

Fingertip injuries are extremely common in children, and severe trauma with pulp loss requires soft-tissue reconstruction to restore length, bulk, and sensibility. The thenar flap is a well-described technique but there are few reports of its use in pediatric patients.

METHODS

Pediatric thenar flap reconstructions were retrospectively identified from October 2000 to October 2010 at a single institution.

RESULTS

Sixteen pediatric patients (eleven male, five female) underwent thenar flap procedures. The average age was 10.8years (1.1-17.8years). The average defect size was 1.5cm×1.5cm (1cm(2)-2cm(2)). Division and inset occurred on average 16days later (12-24days). Average follow-up was 6.8months (4.1-9.6months). The average total active range of motion (TAM) in flexion was 248° (235°-260°) [normal maximum: 260°]. All patients had 85° metacarpophalangeal joint (MCPJ) range of motion (ROM) [normal maximum: 85°]. The average proximal interphalangeal joint (PIPJ) ROM was 103° (95°-110°) [normal maximum: 110°] in flexion, and an average 60° distal interphalangeal (DIPJ) ROM (55°-65°) [normal maximum: 65°] in flexion. Objective sensibility in the flap was ascertained as an average static two-point discrimination of 7mm (6mm-10mm) in 10 compliant patients and was grossly intact in all other patients. There were no complications.

CONCLUSIONS

The thenar flap is a safe and effective option for pediatric fingertip amputation injuries requiring soft-tissue reconstruction.

Secondary healing of fingertip amputations: a review

Most literature on fingertips reviews new surgical techniques of coverage while many surgeons prefer the results of secondary healing. This article reviews the current best evidence and concepts about secondary healing in fingertip injuries.

POSTERIOR INTERBONE ARTERY FLAP FOR COVERING SERIOUS FOREARM, WRIST AND HAND INJURIES

To assess the results achieved with posterior interbone artery flap covering serious injuries of the distal third of the forearm, wrist and hand, evaluating the degree of effectiveness of this procedure.

METHODS

35 patients with serious injuries of the distal third of upper limbs were studied. We assessed the kind of trauma, injury site, flap size, skin coverage need, clinical outcome and complications.

RESULTS

The most frequent mechanism of trauma was motorcycle accident. The most commonly affected regions were: dorsal hand, wrist volar regions and the first commissure. In all patients, the flap size was enough to cover key tissues exposed by the injury. The donor area did not show complications, being primarily closed in 23 cases. The outcomes were good for 31 cases. In 22 patients, no complication was found, and the flap was completely lost in four.

CONCLUSION

Posterior interbone artery flap provides good outcomes in covering serious injuries of the distal third of upper limbs, leading to a stable and reliable coverage, not compromising key irrigating arteries of the hand, enabling the performance of reconstruction procedures. Therefore, this is a useful alternative in such cases.

Soft-tissue injuries of the fingertip: methods of evaluation and treatment. An algorithmic approach

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the anatomy of the fingertip. 2. Describe the methods of evaluating fingertip injuries. 3. Discuss reconstructive options for various tip injuries.

SUMMARY

The fingertip is the most commonly injured part of the hand, and therefore fingertip injuries are among the most frequent injuries that plastic surgeons are asked to treat. Although microsurgical techniques have enabled replantation of even very distal tip amputations, it is relatively uncommon that a distal tip injury will be appropriate for replantation. In the event that replantation is not pursued, options for distal tip soft-tissue reconstruction must be considered. This review presents a straightforward method for evaluating fingertip injuries and provides an algorithm for fingertip reconstruction.

Fingertip injuries

BACKGROUND

Fingertip injuries are extremely common. Out of the various available reconstructive options, one needs to select an option which achieves a painless fingertip with durable and sensate skin cover. The present analysis was conducted to evaluate the management and outcome of fingertip injuries.

MATERIALS AND METHODS

This is a retrospective study of 150 cases of fingertip Injuries of patients aged six to 65 years managed over a period of two years. Various reconstructive options were considered for the fingertip lesions greater than or equal to 1 cm(2). The total duration of treatment varied from two to six weeks with follow-up from two months to one year.

RESULTS

The results showed preservation of finger length and contour, retention of sensation and healing without significant complication.

CONCLUSION

The treatment needs to be individualized and all possible techniques of reconstruction must be known to achieve optimal recovery.

Specific flaps for the thumb

This article illustrates the use of local and distant flaps for the reconstruction of the thumb. The flaps available for thumb reconstructions, particularly of small defects, are often similar to those used in the fingers. However, they are rarely identical and have usually required modification to the particular needs of the thumb. These flaps and their modifications are, perhaps, as important as the few classic flaps used in larger thumb reconstructions, as many defects of the thumb are small and only a few are large. This article attempts to address all of these needs of thumb reconstruction, indicating when small flaps are suitable and when more extensive reconstructions are necessary.

Hand and forearm reconstruction after skin cancer ablation

Skin cancer is common on the dorsum of the hand and forearm. The reconstructive challenges in this area are significant, and the options are myriad. Thus, the surgeon who takes on this challenge must know the various options. These options include the entire reconstructive ladder from direct closure all the way through to composite-free tissue transfer. Nail bed reconstruction should be mastered. In addition, the surgeon should be comfortable with all the reliable flaps, including the kite flap, the cross-finger flap, the reverse cross-finger flap, the rotation-advancement flaps, transposition flaps, and the radial forearm flap.

History of hand surgery in Hong Kong

The development of hand surgery in Hong Kong can be largely divided into three phases: the early years, the 1960s and 70s, and the present. In the immediate post-World War II years, incidence of infectious diseases was high; there were many patients with tuberculosis, poliomyelitis, leprosy and osteomyelitis. In the 1960s and 70s, the light industry revolution brought along many patients with serious hand injuries caused by machines. Dr Yen-Shui Tsao was the first local surgeon trained in hand surgery. Prof. SP Chow and Prof. PC Leung were the two pioneers who developed this subspecialty and microsurgery during that period.

At present, with the change in economic environment, the disease pattern has also changed. Despite our heavy clinical involvement, we have been very active in academic researches. The Hong Kong Society for Surgery of Hand was formed in 1986. For the past 15 years, the society organized Workshops and Annual Congresses attended by overseas speakers, including surgeons from China. It also provided scholarships for Fellows of the Asia-Pacific countries. In addition, the society provided the participants with the chance to exchange ideas and forge friendships. Hong Kong has thus been and will continue to be the meeting point of the East and the West.

Second toe plantar flap for partial finger reconstruction

Utilizing the tissue obtained from the plantar surface (metatarsophalangeal-distal interphalangeal region) of the second toe is an ideal procedure for reconstruction of partial finger tissue defects. The major advantage of this method is that it provides satisfactory aesthetic and functional improvement at the recipient site: furthermore, good results from the aesthetic point of view and minimum morbidity at the donor site are obtained. Our procedure utilizes the free neurovascular skin flap (second toe plantar flap) and full-thickness skin graft. As for the free flap, artery and nerve are obtained from the plantar neurovascular bundle and vein from the dorsal or plantar vein. All cases reconstructed with this procedure revealed satisfactory sensory restoration and aesthetic appearance. The donor sites also revealed no contracture and visible scar. In this paper, we discuss the application of this procedure for finger tissue reconstruction.

A cadaver study on volume and surface area of the fingertip

The volume of the volar soft tissue, dorsal soft tissue, and bone and the area of the dorsal and volar surfaces were estimated in 35 adult cadaver fingertips. The fingertip was defined as the part of the finger distal to the plane of the palmar skin crease and the major dorsal crease at the distal interphalangeal articulation. An impression molding technique, involving silicone rubber, was used to determine the volume, while dyed imprints of the dorsal and palmar surfaces were used to determine the surface area. In all digits, the mean volume of the volar soft tissue of the fingertip was found to be about 56%, the dorsal soft tissue about 26%, and the volume of bone about 18%. The volar soft tissue includes the skin and fascia (51% of the total fingertip volume), the flexor tendon and its sheath, and the volar plate and volar joint capsule (5% of the total). Power relationships for the total fingertip volume, the volume of volar soft tissue, and the volume of bone in terms of the length of the fingertip were noted. There was also a linear relationship found between the volume of the volar soft tissue and the volar surface area. This study provides data on the ratio of soft tissue to bone in the fingertip. The maintenance of the soft tissue-to-bone ratio, so as to regain fingertip form and function, may be of particular importance when designing flaps and coverage in the reconstruction of the fingertip.

Fingertip Injuries: Evaluation and Treatment

The primary goal of treatment of an injury to the fingertip is a painless fingertip with durable and sensate skin. Knowledge of fingertip anatomy and the available techniques of treatment is essential. For injuries with soft-tissue loss and no exposed bone, healing by secondary intention or skin grafting is the method of choice. When bone is exposed and sufficient nail matrix remains to provide a stable and adherent nail plate, coverage with a local advancement flap should be considered. If the angle of amputation does not permit local flap coverage, a regional flap (cross-finger or thenar) may be indicated. If the amputation is more proximal or if the patient is not a candidate for a regional flap because of advanced age, osteoarthritis, or other systemic condition, shortening with primary closure is preferred. Composite reattachment of the amputated tip may be successful in young children. The outcome of nail-bed injuries is most dependent on the severity of injury to the germinal matrix.

Hook-nail deformity. Surgical treatment with a homodigital advancement flap

Sixteen patients presenting 18 hook-nail deformities have been treated by the advancement of a homodigital island flap. With an average follow-up of 31 months; Results were considered good or excellent in seven cases, fair in seven and poor in four. Six cases, although improved, had a marked recurrence of the deformity, six had a partial recurrence and six had almost no recurrence. Patient satisfaction was limited as the finger still had a short nail and a square shape.

A simple and efficient treatment for fingertip injuries

We have developed a simple, cheap and efficient method of management of fingertip injuries using an occlusive dressing--the fingertip cap (Hyphecan). The results of 156 fingertip injuries treated with this method demonstrate recovery to a near normal fingertip.

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

We reviewed 43 Hueston flaps in 41 patients (average age, 35 years) following distal fingertip skin loss. Mean advancement of the flap was 13 mm. Patients with single-digit injuries missed an average of 36 days off work. At the follow-up evaluation (mean, 3 years), 10 patients complained of pain (1 with functional impairment), 30 complained of cold intolerance, and 24 had nail deformities. Sensibility of advanced skin was normal by Semmes-Weinstein test in 33 cases, while two-point discrimination averaged 7 mm. This discrimination was virtually identical to contralateral digits in 31 of the cases. Overall, 30 patients were satisfied with their results, while 11 patients were mildly displeased. In 10 patients, this involved impairment of function, while the remaining patient was displeased with the appearance.

Treatment of finger-tip injuries with silver sulphadiazine occlusion dressing

From 1982, patients with finger-tip injuries were treated with sulphadiazine occlusion dressings. The average time taken for the wound to heal, incidence of infection and absence from work were studied. The results of this method gave consistently good results when compared with other techniques which are summarized.

Dressings of the Nailbed following Nail Avulsion

Dressings of the raw nailbed tend to adhere and to be difficult and painful to remove. We have compared three types of dressing: polyurethane sponge, paraffin-gauze and replacement of the finger-nail. Assessment of adherence and pain showed that replacement of the nail had significant advantages over the other dressings.

Hydrofluoric acid burns of the hand: mechanism of injury and treatment

Hydrofluoric acid is one of the strongest inorganic acids and is used extensively in industry and research. It differs from other acids in that the fluoride ion readily penetrates the skin, causing destruction of deep tissue layers and even bone. Authors have previously described numerous topical treatments. This report describes one method of treatment emphasizing immediate skin cleansing and the application of calcium gluconate gel, which is followed by calcium gluconate subcutaneous injections when necessary. An accurate occupational history and physical examination are important aspects of patient assessment. Prompt treatment resulted in relief of pain and a satisfactory clinical result in all cases. A significant delay in treatment was responsible for permanent impairment in 2 of 14 patients.

Open finger tip healing and replacement after distal amputation in rhesus monkey with comparison to limb regeneration in lower vertebrates

The left thumbs and great toes of three 8 1/2 month old Rhesus monkeys (Macaca mulatta) were amputated in guillotine fashion one millimeter distal to the base of the nail and allowed to heal by the conservative open wound method. Healing occurred in seven to ten days in these small digits. Each of the thumbs and toes grew back with some blunting and shortening of the digit tips, but were functional. The new structures were cosmetically pleasing as in the human instances. The nails grew essentially to normal size and shape supported by the remaining portions of the distal phalanges. Histological studies showed no evidence of blastema formation such as is observed in the regenerating limb of the Urodele (newt) taken as the comparative representative. The possibility of improving the regrowth is discussed against the background of our knowledge of the importance of nerve during limb regeneration in lower vertebrates.

Conservative treatment of fingertip injuries

In a prospective investigation of 81 consecutive patients with fingertip injuries conservative treatment was evaluated. Fingertip injuries were defined as lesions greater than or equal to 1 cm2 in the terminal phalanx without injury to the tendons or joints. All fingertip injuries were cleaned and covered by Vaseline gauze and left to heal. If less than 2 mm of soft tissue covered the bone a few millimetres of bone were nibbled away to allow good cover with soft tissue. The majority of injuries (64 per cent) occurred at work. The average healing time was 25 days. The main later complaints were intolerance of cold (36 per cent), numbness (36 per cent) and tenderness (26 per cent). None of the patients had stiff joints. On average, the two-point discrimination had increased by 1 mm in the injured fingertip. Conservative treatment is recommended as a safe and simple treatment of fingertip injuries, even when bone is exposed in the wound.

The Use of Semipermeable Dressings in Fingertip Injuries

A randomised prospective trial was carried out to compare the use of semipermeable and petroleum gauze dressings in fingertip injuries. The results demonstrate advantages in the use of semipermeable dressings.

Restoration of the pulp with a homodigital neurovascular flap

A homodigital neurovascular island flap was used to cover extensive loss of finger tip tissue exposing the distal phalanx in twenty cases (16 adults and 3 children). The anatomic and technical aspects of this flap are detailed. In all cases, the reconstructions were considered to be of excellent quality. The study of functional results substantiates the reliability of this island flap, for which sensibility remained good throughout the follow-up period.

Management of injuries of the distal phalanx

A series of 90 injured fingertips is presented with a practical approach to the treatment of these injuries, along with a discussion of their complications.