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Management of Thumb Tip Injuries

Gnter Germann, MD, PhD, Michael Sauerbier, MD, PhD,
Klaus D. Rudolf, MD, Manuel Hrabowski, MD
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Ghazi M. Rayan, MD, has no relevant conicts of interest to disclose.
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Copyright 2015 by the American Society for Surgery of the Hand. All rights reserved.

Discuss the treatment principles of thumb tip injuries.

Describe the role of the Moberg ap in the management of thumb tip injuries.
Review the role of the rst dorsal metacarpal artery island ap in the management
of thumb tip injuries.
Highlight the role of reverse ow homodigital aps in the management of thumb
tip injuries.
Assess the literature regarding the treatment outcome of thumb tip injuries.

Current Concepts

The management of thumb tip injuries has undergone great changes in recent years. The
traditional armamentarium of aps has been expanded and replaced by a wide variety of aps
with more versatility and less donor side morbidity. Parallel to the development of new aps, the
conservative treatment of thumb tip injuries with semi-occlusive dressing has gained ground in
the treatment of these injuries. Although tedious and time-consuming, and requiring intensive
communication with the patient to explain the look and occasionally fetid smell of the wound,
this technique yields excellent results with respect to restoring contour and sensibility in pulp
injuries. The article gives an update on the current options for treating thumb tip injuries
including the most commonly applied aps. (J Hand Surg Am. 2015;40(3):614e622. Copyright
 2015 by the American Society for Surgery of the Hand. All rights reserved.)
Key words Thumb, tip injuries, treatment concepts.
From the Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg,
Received for publication July 26, 2014; accepted in revised form September 28, 2014.
No benets in any form have been received or will be received related directly or indirectly
to the subject of this article.


 2015 ASSH

Published by Elsevier, Inc. All rights reserved.

Corresponding author: Gnter Germann, MD, PhD, University of Heidelberg Ethianum for
Clinic Plastic, Hand and Reconstructive Surgery, Vostr. 6, 69115 Heidelberg, Germany;





J Hand Surg Am.


Extensive thumb defects with exposure of tendons,
bone, or joints present a challenging reconstructive
problem. Immediate coverage of the wound has the
highest priority to preserve aesthetic and function. A
variety of aps is routinely used for reconstruction of
the thumb.
Moberg ap
In the thumb, the palmar advancement ap rst
described by Moberg13 in 1964 has special importance. The ap is an advancement ap based on
proper neurovascular bundles for coverage of palmar
defects of the pulp. It is considered a standard ap for
reconstruction of medium defects 2 cm or smaller.33
In 1968, OBrien34 was the rst to describe a modication of this technique by converting this
advancement ap into an island ap to cover larger
defects. Performing bilateral Z-plasties at the base of
the ap as well as dividing the subcutaneous septa
avoids exion contracture of the interphalangeal joint
as described by Germann.35 Distal procedures such
as VeY extensions,36 Burrow triangles,37 or fullthickness skin grafts after division of the proximal
skin bridge34 have been described to increase ap
mobility. In large defects with bone exposure,
shortening of the bone may be considered but it may
result in reduced strength in pinch grip. The Moberg
ap remains the reference standard for covering
complex distal thumb pulp defects (Fig. 1).
First dorsal metacarpal artery ap
One of the most frequently employed procedures is
the rst dorsal metacarpal artery (DMCA) ap, also
known as the Kite ap, described by Foucher
et al38,39 in 1978. This ap is based on the work of
Holevich40 (1963) and Hilgenfeldt41 (1950). It is
based on the rst dorso-metacarpal artery and usually

Vol. 40, March 2015

Current Concepts

(cross-nger),16,17 distant island aps (homodigital),18e22 and heterodigital,23 metacarpal perforator,24 and microsurgical free.25e32
Among these numerous options, the reconstructive
surgeons duty is to choose the best method that
meets the patients needs. Because of the specic
anatomical characteristics and highly sophisticated
function of the ngertips, it has long been believed
that palmar defects of the ngertip should be reconstructed using palmar skin that has characteristics
similar to those of the ngertip. However, because
there is a possibility of postoperative scar contracture
at the ap donor site, other aps have also been
commonly used.

most frequently
encountered injuries in the upper limb, because
it is the main autologous tool used by primates
and humans. The ngertips are the most important
organs of tactile sensibility. Two-point discrimination
usually is below 5 mm owing to the density of
VaterePacini bodies and the branches of the palmar
digital nerves responding to tactile stimuli and
providing skin sensibility. The anatomic structures of
the pulp with its subcutaneous architecture are laid
out to withstand substantial pressure and shear force.
Rich arterial blood is supplied to the ngertip by
terminal branches of the main palmar digital arteries.
Venous blood drainage on the palmar side is provided
by the supercial palmar veins and oblique communicant veins.
Classication of thumb tip defects is not clearly
dened in the literature. Usually defects are dened
arbitrarily as small or large.1 Other denitions use the
structures involved such as the pulp, nail, and bone,
which also dene the location of the injury.2,3 Using
both criteria denitions most likely gives the best
basis for selecting the appropriate reconstructive
The selected technique of defect reconstruction
depends on many factors such as the nature of the
injury; the size, location, and condition of the defect;
the patients age, gender, and general health condition; and the patients professional prole.
The goals in ngertip amputation reconstruction
are to cover the defect with a satisfactory cosmetic
appearance, establish maximum tactile gnosis, preserve the length of the thumb, obtain a well-padded
pulp tissue, preserve an intact nail bed, and minimize time off work.
Numerous methods for reconstructing ngertips
are described in the literature, which correlate to the
principle of the reconstructive ladder. These range
from healing by secondary intention and skin grafting
to simple palmar VeY plasty and bilateral VeY
plasty,4e6 various island aps, and even free toe pulp
transfer for large defects. Skin grafting of the defect is
an easy method but usually results in poor sensory
function; therefore, it should be considered only if
other options are not feasible. Healing by secondary
intention (eg, under a semi-occlusive dressing) has
been established as a good method for small to medium defects without exposure of bone or tendons. If
successful, it results in an excellent contour and
consistency of the pulp with satisfactory return of
sensory function.
Flaps used for thumb tip reconstruction are
classied as homodigital aps,4e15 heterodigital




FIGURE 1: A Palmar defect of the tip of the thumb after debridement. B Dissection of the Moberg ap based on the proper neurovascular bundles. C The ap is advanced and sutured into the defect.

includes the sensory branch of the radial nerve.

Although the kite ap was primarily intended for
dorsal defects, it is frequently used to restore thumb
sensibility in case of loss of the pulp.42 The kite ap
provides immediate sensibility and is therefore
especially indicated in older patients, in whom nerve
coaptations do not yield satisfactory results. Secondary defect reconstruction is usually performed
with full-thickness skin grafts (Figs. 2, 3).
Although the kite ap has evolved as the workhorse for thumb reconstruction, alternatives may be
needed when the index nger is not available as a
donor site. Many anatomical studies have described
the constant and predictable anatomy of the dorsoulnar and dorsoradial branch artery of the
thumb.5,39,43e45 This led to the development of aps
from the dorsum of the thumb metacarpal area.

phalanx to protect communication with the palmar

vessels. The arc of rotation of the ap allows
coverage of the distal palmar or dorsal parts of the
thumb as well as radial defects of the proximal and
distal phalangeal areas48,49 (Fig. 4). Flap size ranges
from 2  2 to 5  4 cm.
Reversed ow ulnar homodigital pedicled ap
A reversed ow pedicled homodigital ap based on
the dorsoulnar collateral artery was rst described by
Brunelli in 1993.50 Pagliei described a successful
series of 32 cases.51 The dorsoulnar collateral artery,
which originates from the palmar arteries, runs
supercially within the subcutaneous tissue and the
ap is centered over the dorsoulnar aspect of the rst
metacarpal. Flap dissection is similar to the technique
of Moschella et al.46,47 This ap is suitable for
covering small to medium defects of the dorsal and
palmar side of the thumb51 (Fig. 5).
With these types of aps, the index nger can be
spared as a donor site and the rst DMCA has no longer to be sacriced because it represents an important
vessel for the dorsum of the hand as well as the interosseus muscle.

Current Concepts

Reversed ow radial homodigital pedicled ap

The radial reversed ow pedicled ap was rst described by Moschella and Cordova46 in 2006, based
on their anatomical studies47 in 16 patients. It is
raised on the dorsoradial side of the rst metacarpal
area and is based on the dorsal radial collateral artery, which has constant anatomy including course,
caliber, and communication with the palmar network.
The dorsoradial artery originates from the radial
artery at the level of the anatomical snuffbox
and passes under the extensor pollicis brevis tendon
to the middle of the thumb proximal phalanx,
which is the pivot point of the ap. The dorsoradial
collateral artery communicates with the palmar
network at the level of the middle third of the
proximal phalanx.
Preoperatively, a Doppler examination helps to
identify the course of the vessel and mark the pivot
point. At no point of the surgical procedure must the
pedicle be visualized, and a wide strip of subcutaneous tissue is included to ensure venous outow
and avoid kinking. Dissection of the ap should not
be extended beyond the middle third of the proximal
J Hand Surg Am.

Semi-occlusive dressing
Treatment of ngertip injuries with a semi-occlusive
dressing is simple and inexpensive.52e54 The wound
is covered with a transparent adhesive dressing after
cleaning and debridement (Figs. 6, 7). For protection
and to avoid slipping of the transparent adhesive dressing, an additional cover is added with a soft crepe
bandage. The patient is instructed to make full use of the
hand and the injured nger without immobilization.
The dressing is left in place for 1 week (at least 5 d) and
is then replaced on a weekly basis until the wound
completely heals. During dressing changes it is necessary to clean the skin close to the defect without
cleaning the wound itself before the new dressing is
applied. It is important not to change the dressing
frequently, to avoid contamination and reduce the

Vol. 40, March 2015



outside.52 With this simple and inexpensive method,

defect closure is achieved in a reasonably short time.
Depending on the size of the defect and the individual
constitution, the time for complete wound closure is
normally 2 to 8 weeks. After that, the pulp regains an
almost normal contour and in many cases the thumb or
ngerprint shows complete restitution (Fig. 7). Sensibility returns to normal within a few weeks.

wound infection rate. It is normal for the wound to smell

putrid and for the skin to be macerated in the area of the
transparent adhesive dressing. The semi-occlusive
dressing acts as an articial skin that preserves the
pH, temperature, polymorph accumulation, immunoglobulin concentration, and moisture.53 The semiocclusive dressing allows diffusion of oxygen and
prevents further contamination by organisms from
J Hand Surg Am.

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Current Concepts

FIGURE 2: A Hydrouoric acid burn of the tip of the thumb with loss of the nail bed and exposure of the proximal phalanx. B Start of
dissection of the rst DMCA ap. It is important to preserve the large subcutaneous veins to provide the best possible venous outow.
C The ap is raised and the vascular pedicle is secured by including the fascia of the interosseus muscle. D The ap after healing and
incorporation into the defect.



FIGURE 3: A Recurrent arteriovenous malformation involving the entire palmar tip of the thumb. B Resection defect after complete
removal of the vascular tumor. C Tip reconstruction with a neurovascular-sensible rst DMCA ap to restore sensibility and the soft
tissue defect simultaneously. D The ap at 2 weeks after surgery.

Current Concepts

Advances in anatomical knowledge, progress in surgical instruments and available devices, and innovative surgical techniques have enhanced soft tissue
reconstruction of the hand. Constant improvement in
design and harvesting techniques has led to ap renements resulting in considerably more appealing
aesthetic results in soft tissue reconstruction.
Although local ap coverage has the benet of
preserving the thumb length and is preferred for
wound closure after bone shortening, it is unfeasible
J Hand Surg Am.

in patients with extremely large defects or in cases

where the adjacent tissue is in poor condition. Local
homodigital aps are easy to apply, they do not need
microsurgical instruments, the surgical time is relatively short, they do not need a prolonged immobilization period, and they allow patients to return to
work early.
Larger defects may require regional aps such
as the rst DMCA ap38,39 or even microsurgical
solutions such as hypothenar perforator ap55 or free
pulp ap from the great toe.30,31

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However, because of the limited availability of

local soft tissue, reconstruction of thumb tip injuries
and acceptable functional and cosmetic outcomes
remain challenges for the hand surgeon.
The intrinsic aps are well-established for thumb
tip reconstruction in complex defects. However, in
recent years the methods of thumb tip reconstruction
have changed dramatically. The treatment regimen
using a semi-occlusive dressing has become
increasingly popular in less complex situations.
Three criteria determine the choice of the ideal
reconstruction method of the thumb tip: the size of
the defect, the structures involved (skin, soft tissue,
and bone), and the location of the injury (palmar,
radial, ulnar, or dorsal).
Consideration for reconstructive principles is
frequently based on defect size. Based on the fact that
the size of a male thumb tip is 3 to 4 cm long and 1.5
to 2.5 cm wide, defects of 4 cm2 comprise approximately 50% of the entire surface of the thumb tip. We
recommend splitting the defects into 2 groups: one
that comprises less than 50% (4 cm2 or less) and
one more than 50% of the size of the tip of the thumb
(4 cm2 or more). The characteristics of the tissue
J Hand Surg Am.

involved and the location are equally important

criteria in the decision-making process.
The studies of Mennen and Wiese54 and Quell
et al56 showed that the main benets of the semiocclusive dressing method are reconstruction of
the tip with good skin quality, normal sensibility,
retained motion, lack of pain, good aesthetics, and no
donor site morbidity. However, no studies mentioned
defect sizes treated with this method. These results
and reports from other groups54 make this noninvasive method the procedure of choice in most defects,
whenever applicable.
If the defect is more than 50% of the size of the tip
of the thumb (4 cm2 or more) or has a fracture of the
bone or joint involvement, reconstruction with an
intrinsic, regional, or even free ap is indicated. The
location of the injury helps in selecting the best ap.
Dividing the thumb tip into 4 areas helps the decision.
For injuries of the palmar tip the Moberg ap remains
the workhorse. It provides immediate sensory function
and a normal ngerprint pattern. Advancement of the
ap is limited to 1.0 to 1.5 cm. In larger defects VeY
extensions, Burrow triangles at the base of the ap, or
full-thickness skin grafts after dividing the proximal

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Current Concepts

FIGURE 4: A Avulsion injury of the dorsal tip of the thumb with loss of the nail bed and exposed bone. B Design of the reversed radial
ow homodigital ap (Moschella ap). C The ap is raised based on the recurrent dorsal radial artery. D The ap is sutured into the



FIGURE 5: A An ulnar reversed-ow homodigital island ap (Brunelli ap) is raised on the dorsal ulnar recurrent artery. B A small dog
ear is left in this case to protect the vascular pedicle. C Another case in which the ap is used for tip reconstruction.

Current Concepts

skin bridge may be indicated. Drawbacks of this ap

may be exion contracture of the interphalangeal
joint or a parrot nail deformity in rare cases.
For larger defects in this region, the sensate rst
DMCA ap has evolved as a useful option. Based on
the work of Trnkle et al,42 the ap provides immediate
sensation by including the sensory branch of the radial
nerve. The incidence of dual location phenomenon is
low, which indicates that sensory reeducation of the
cortex is excellent. This is a major advantage in older
patients, in whom nerve coaptation or innervated free
aps yield worse results with a much longer healing
The radial reversed ow homodigital island ap
described by Moschella et al46,47 is an excellent option for radial tip defects. With this ap, large defects
can be covered sufciently with minor donor side
morbidity, often without skin graft. This ap is also
excellent for covering dorsal tip injuries. The prerequisite for using this ap is that the area of the pivot
J Hand Surg Am.

FIGURE 6: Principle application of the semi-occlusive dressing.

Fluid accumulation is normal. Dressing changes are performed at
intervals of 5 to 7 days.

point and the surrounding tissue remain intact to

guarantee blood supply through the recurrent dorsal
radial artery.

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FIGURE 7: A Clinical example of an oblique thumb tip amputation with a jagged blade. The nail bed is partially preserved. B Dorsal
aspect of the wound. C, D Clinical appearance at 1 and 2 weeks after treatment with semi-occlusive dressing. Slight maceration of
healthy skin is caused by the dressing material. E After approximatly 4 weeks, the thumb tip has an almost normal contour. Nail growth
has returned. The ngerprint pattern is not yet completely restored.

armamentarium of aps is available, ranging from

intrinsic aps to small free aps, which can be
customized to the requirements of the patient.

For reconstruction of the dorsal tip and nail bed, the

ulnar reversed ow homodigital ap described by
Brunelli,50 the radial reversed ow homodigital island
ap, and the rst DMCA ap can be used, depending
on the defect size. Restoration of sensory function is
not of utmost importance in these cases, so all aps
are equally suitable. The DMCA ap can be harvested
in a size that facilitates coverage of the entire dorsum
of the thumb. Selection of the ap depends mainly on
the condition of the donor site (ie, if the pedicle intact
or if there is contusion in the pivot point area).
Treatment of an ulnar tip injury of the thumb
presents a special challenge. The ulnar tip is one of
the most important tactile areas in the hand and
provides a 3-point pinch grip and key pinch in both a
delicate and forceful fashion. Excellent sensory
function is therefore necessary for normal hand
function and the development of grip strength. The
DMCA ap has indisputably become the workhorse
in cases where the Moberg ap is not suitable for
covering the defect and the conservative semiocclusive method is not considered appropriate.
Numerous options exist for the reconstruction of
thumb tip defects. The semi-occlusive method has
evolved into the standard procedure. Because this
technique provides excellent restoration of contour,
volume, and sensibility, it is suitable for most small
to midsize thumb tip defects. For larger, complex
defects, ap reconstruction is still useful. A broad
J Hand Surg Am.

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Current Concepts

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J Hand Surg Am.

Vol. 40, March 2015