You are on page 1of 3

Fingertip Reconstruction

Kyle D. Bickel, MD, Amarjit Dosanjh, MD
THE PATIENT
A 33-year-old professional chef amputated the tip of
her dominant left long finger on a blender blade while
preparing food. She was initially treated at a local
emergency department: she received intravenous antibiotics, radiographs were taken, and the wound was
cleansed and dressed. She was referred for hand surgical care and presented 2 days after the injury for treatment. Examination revealed an oblique amputation of
soft tissue involving the pulp distal to the sterile matrix,
the radial half of the sterile matrix and radial soft
tissues, and the radial eponychial fold, with exposure of
the distal phalangeal bone (Fig. 1).
THE QUESTION
What is the best method for reconstructing distal composite tissue fingertip amputations?
CURRENT OPINION
Secondary healing with dressing changes; debridement,
shortening, and primary closure; split- or full-thickness
skin grafting; homodigital flap reconstruction; heterodigital flap reconstruction; and pedicled flaps are all
advocated and commonly used in the treatment of distal
composite fingertip amputations.
THE EVIDENCE
The majority of scientific reports on this subject are
retrospective case series. To our knowledge, the only 2
comparative studies are also retrospective, but both
addressed relatively superficial tissue loss rather than
composite loss. In one study, primary closure was compared with split-thickness skin grafting in 79 injuries,
and there was no difference in functional outcomes
between the 2 approaches.1 Results were stable beFrom the UCSF School of Medicine, The Hand Center of San Francisco, San Francisco, CA; and the Division of Plastic Surgery, UCSF School of Medicine, San Francisco, CA.
Received for publication June 17, 2008; accepted in revised form July 1, 2008.
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.
Correspondingauthor:KyleD.Bickel,MD,TheHandCenterofSanFrancisco,1700CaliforniaSt.,
Suite 450, San Francisco, CA 94109; e-mail: kbickel@sfhand.com.
0363-5023/08/33A08-0027$34.00/0
doi:10.1016/j.jhsa.2008.07.001

tween 6 and 42 weeks after the procedures, and the
difference in time to return to work was not statistically
significant between the 2 approaches. In the other study,
a comparison of long-term results in fingertip amputations with exposed distal phalangeal bone treated with
various surgical and nonsurgical methods revealed no
difference in outcomes at greater than 1-year of
follow-up.2
The question of how best to address fingertip amputations has been extensively addressed with review articles that summarize the data from numerous retrospective case series describing the results of various
treatment options.3–5 Emphasis is typically placed on
the pattern of injury with particular emphasis on involvement of distal phalangeal bone and nail matrix.
The size and depth of tissue loss are also cited as
primary determinants of conservative versus surgical
management, with conservative management most often recommended for smaller wounds with minimal
bony exposure or nail matrix involvement. When bone
is not exposed and tissue loss is superficial, the results
from management with dressing changes and secondary
healing are generally believed to be superior to skin
grafting, with better sensory return and aesthetics and
no difference in hand function.2,6,7 Secondary healing is
contraindicated for all but the smallest bony tuft exposures. In anything larger, the risk of bony dessication/
necrosis and/or osteomyelitis outweighs the benefits,
and soft tissue coverage is necessary. Once a surgeon
commits to secondary healing, it can be more difficult
to get satisfactory results from flap reconstruction later
on, as the finger has proceeded through marked remodeling and wound contraction, and the morphology of
the unique structures, such as the eponychial fold, sterile matrix, and distal pulp, has been changed.
Several homodigital flaps have been recommended
for the treatment of fingertip amputations. Both Kutler8
and Atasoy9 described V-Y advancement flaps that are
still in wide use with little or no modification. Tupper
and Miller analyzed 16 patients with 20 volar V-Y flaps
and found decreased 2-point discrimination and
Semmes-Weinstein monofilament testing in all, with an
average 73% of normal sensitivity.10 In contrast, Kartik
analyzed 29 volar V-Y flaps and found sensation had
returned to near-normal levels within 3 months when

©  ASSH ! Published by Elsevier, Inc. All rights reserved. ! 1417

Evidence-Based Medicine

EVIDENCE-BASED MEDICINE

1418

FINGERTIP RECONSTRUCTION

Evidence-Based Medicine
FIGURE 1: Oblique amputation of the distal soft tissue of the
long finger with 30% loss of the sterile matrix and exposure of
the distal tuft.

compared with uninvolved digits.11 Foucher et al. evaluated a series of 43 volar advancement flaps in patients
with an average age of 35 years and found return of
normal sensation in 77%, cold intolerance in 73%, and
persistent pain in 25% at a mean follow-up of 3 years.12
Pelissier et al. reported on 15 cases of distal fingertip
amputation treated with dorsal transposition flaps. The
average 2-point discrimination was 8 mm, and 66% of
patients lost between 10° and 35° of distal interphalangeal (DIP) joint arc of motion.13 Two smaller series
reported on use of digital island flaps with return of
sensation of between 3 and 6 mm without reported loss
of joint motion. Both series reported adequate bone
coverage.14,15
Heterodigital flaps have also been reported in treating composite fingertip amputations since first reported
by Littler in 1953. These flaps involve the transfer of
composite tissue on an arteriovenous pedicle from one
digit to another within the same hand. Tsai and Yuen
reported on 16 patients treated with neurovascular island flaps with 2-years of follow-up. Average range of
motion was normal at the metacarpophalangeal, proximal interphalangeal, and DIP joints. Two-point discrimination of less than 10 mm was achieved in 75% of
the flaps. Nineteen percent of patients complained of
hypersensitivity or stiffness, and 38% complained of
cold intolerance.16 In contrast, a review by Teoh et al.
of 29 flaps revealed preservation of normal motion and
sensation in the donor finger and 100% flap survival,
normal sensation, and no cold intolerance in the recipient bed.17
Reports of staged pedicled flap reconstruction of
fingertip amputations have focused on cross-finger
flaps and thenar flaps. Nishikawa and Smith reported
a series of 54 cross-finger flaps for reconstruction of
fingertip injuries. All achieved protective sensation

in the reconstructed digits, but none achieved the
return of tactile gnosis. Cold intolerance was reported in 53% of patients. Nonetheless, subjective
patient satisfaction was 92%.18 Melone et al. reviewed 150 thenar flaps in patients with an average
age of 35 years, with 20% greater than 50 years.19
Their technique emphasized placement of the flap
distally on the thenar area, with 1 border based at the
metacarpophalangeal joint flexion crease, and flap
division no later than 14 days. The flaps were all
based radially on the thenar mass. All flaps recovered
protective sensation and an average static 2-point
discrimination of 7 mm in the flaps. Four percent of
the patients developed interphalangeal joint contractures. The authors concluded that rigid age limitations were not warranted in use of thenar flaps.
Rinker evaluated 17 thenar flaps (only 3 in patients
over age 45 years) after an average of 20 months.20
He found no proximal interphalangeal joint contractures in the group but a notable decrease in DIP joint
range of motion. Mean static 2-point discrimination
was 6.8 mm in the reconstructed fingertips versus 3.8
mm in the uninjured contralateral digits. Fitoussi et
al. documented similar results using a thenar flap in
12 children.21
SHORTCOMINGS OF THE EVIDENCE AND
DIRECTIONS FOR FUTURE RESEARCH
There is insufficient evidence to determine the best
treatment method for composite defects of the fingertips. To date, there have been no prospective, randomized clinical trials to evaluate one method versus another. The 2 retrospective comparative series are
limited in their scope, addressing the treatment of superficial soft tissue loss without notable composite tissue involvement.1,2 The multitude of case series with
level IV evidence evaluating the various methods of
composite tissue reconstruction are too disparate with
respect to methods of evaluation, numbers of subjects,
and objective and subjective criteria for analysis to
allow for comparison and definitive conclusion.
Much of the disparity in the literature, however,
comes from variation in the injuries themselves. The
existing classification systems are useful22,23 but complicated by the highly variable nature of the injuries
with respect to orientation, tissue quality, vascularity,
and patient factors such as age, hand use and occupation, smoking history, and concurrent diseases.
Future studies should develop and use standard
methods for evaluating both subjective and objective
results. Outcomes scores such as the Disabilities of the
Arm, Shoulder, and Hand questionnaire and the Mich-

JHS ! Vol A, October 

igan Hand Outcomes Questionnaire would be useful
measures of disability. Prospective, randomized clinical
trials comparing treatment methods are merited and
should be feasible.
CURRENT CONCEPTS
For fingertip amputations with exposure of underlying
bone and involvement of the nail matrix, the available
evidence suggests that reconstruction with one of the
many available flaps will generally yield satisfactory
results with adequate soft tissue coverage, preservation
of tip length and contour, return of protective sensation,
and minimal donor-site morbidity. The thenar flap is
our preference, because when properly designed and
executed it allows for the transfer of larger volumes of
tissue than do local advancement flaps and can minimize morbidity in the already injured finger.
REFERENCES
1. Braun M, Horton RC, Snelling CF. Fingertip amputation: review of
100 digits. Can J Surg 1985;28:72–75.
2. Soderberg T, Nystrom A, Hallmans G, Hulten J. Treatment of
fingertip amputations with bone exposure. A comparative study
between surgical and conservative treatment methods. Scand J Plast
Reconstr Surg 1983;17:147–152.
3. Hart RG, Kleinert HE. Fingertip and nailbed injuries. Emerg Med
Clin North Am 1993;11:755–765.
4. Martin C, Gonzalez del Pino J. Controversies in the treatment of
fingertip amputations. Clin Orthop Relat Res 1998;353:63–73.
5. Sammut D. Fingertip injuries: a review of indications and methods of
management. Curr Orthop 2002;16:271–285.
6. Mennen U, Wiese A. Fingertip injuries: management with semiocclusive dressing. J Hand Surg 1993;18B:416 – 422.
7. Lamon RP, Cicero JJ, Frascone RJ, Hass WF. Open treatment of
fingertip amputations. Ann Emerg Med 1983;12:358 –360.

1419

8. Kutler W. A new method for fingertip amputations. JAMA 1947;
133:29 –30.
9. Atasoy E, Ioakimidis E, Kasdan ML, Kutz JE, Kleinert HE. J Bone
Joint Surg 1970;52A:921–926.
10. Tupper J, Miller G. Sensitivity following volar V-Y plasty for
fingertip amputations. J Hand Surg 1985;10A:183–184.
11. Kartik GK. Sensory recovery after reconstruction of defects of long
fingertips using the pedicled v flap. Br J Plast Surg 2001;54:523–
527.
12. Foucher G, Dallaserra M, Tilquin B, Lenoble E, Sammut D. The
Hueston flap in reconstruction of fingertip skin loss: results in a
series of 41 patients. J Hand Surg 1994;19A:508 –515.
13. Pelissier P, Genin-Etcheberry T, Casoli V, Martin D, Baudet J.
Limits and indications of the dorsal transposition flap: critical evaluation of 15 cases. J Hand Surg 2001;26A:277–282.
14. Takeishi M, Shinoda A, Sugiyama A, Ui K. Innervated reverse
dorsal digital island flap for fingertip reconstruction. J Hand Surg
2006;31A:1094 –1099.
15. Tuncall D, Barutcu AY, Gokrem S, Terzioglu A, Aslan G. The
hatchet flap for reconstruction of fingertip amputations. Plast Reconstr Surg 2006;117:1933–1939.
16. Tsai TM, Yuen JC. A neurovascular island flap for volar-oblique
fingertip amputations. Analysis of long-term results. J Hand Surg
1996;21B:94 –98.
17. Teoh LC, Tay SC, Yong FC, Tan SH, Khoo DB. Heterodigital
arterialized flaps for large finger wounds: results and indications.
Plast Reconstr Surg 2007;119:2321–2322.
18. Nishikawa H, Smith PJ. The recovery of sensation and function after
cross-finger flaps for fingertip injury. J Hand Surg 1992;17B:102–
107.
19. Melone CP, Beasley RW, Carstens JH. The thenar flap—an analysis
of its use in 150 cases. J Hand Surg 1982;7:291–297.
20. Rinker B. Fingertip reconstruction with the laterally based thenar
flap: indications and long-term functional results. Hand 2006;1:2– 8.
21. Fitoussi F, Ghorbani A, Jehanno P, Frajman JM, Pennecott GF.
Thenar flap for severe finger tip injuries in children. J Hand Surg
2004;29B:108 –112.
22. Evans DM, Bernardis C. A new classification for fingertip injuries.
J Hand Surg 2000;25B:58 – 60.
23. Rosenthal EA. Treatment of fingertip and nail bed injuries. Orthop
Clin North Am 1983;14:675– 697.

JHS ! Vol A, October 

Evidence-Based Medicine

FINGERTIP RECONSTRUCTION