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Treatment of Fingertip Injuries

Thomas M. Neustein, MD
Samuel H. Payne Jr., MD
John G. Seiler III, MD
Abstract
» The goal of care when treating fingertip injuries is to minimize the
risk of infection while maximizing function, tactile sensation, digit
length, pulp padding, and appearance. This outcome can be achieved
with careful soft-tissue coverage and, if possible, nail-bed preservation.

Investigation performed at Georgia
Hand, Shoulder, and Elbow, Atlanta,
Georgia
Downloaded from http://journals.lww.com/jbjsreviews by BhDMf5ePHKbH4TTImqenVFao8o3NFiILKzZarx7frmI+Ccr9U2CExSpRx+Zd9drQgMD43Ytz850= on 05/04/2020
» When replantation for a fingertip amputation is not possible for
anatomic or logistical reasons, local or regional flap reconstruction can
be a useful alternative to gain early soft-tissue coverage and allow
more functional rehabilitation.

» Reviewing current fingertip soft-tissue coverage procedures and

demonstrating key anatomic and technical points with cadaveric
dissections provides a foundation for the incorporation of these
techniques into practice.

O
ver 4.8 million patients
present to the emergency
room with hand and finger
injuries each year1. Among
these injuries are complete or partial
amputations of the digits, which often
provide a complex problem for the treating
surgeon. When the injury is not amenable
to replantation because of the location of
the injury, crush or contamination, or
prolonged ischemia, the surgeon may
choose among various soft-tissue coverage
techniques. The goal of care is to minimize
the risk of infection while maximizing
function, tactile sensation, digit length, pulp
padding, and appearance. These outcomes
can be achieved with careful soft-tissue
coverage and, if possible, nail-bed preserva-
tion2. The purpose of the present article was
to review the indications for current fingertip
soft-tissue coverage procedures and demon-
strate key anatomic and technical points.
induced finger necrosis, no cases of the
condition have been reported4.
Single or double-injection techniques
can be utilized, although we prefer the single-
injection technique to minimize needle-
sticks. The hand is placed on the table with
the palm up and the skin is cleaned. A needle
is inserted vertically in the digit midline and
at the level of the palmar digital crease into
the deep subcutaneous tissues. The injection
is done slowly into the subcutaneous tissues
so that the adjacent digital nerves are bathed
in the local anesthetic agents. Ten cc of 1%
lidocaine injected via this method should
sufficiently anesthetize the digit. A conve-
nient method for exsanguination of the digit
and application of the tourniquet involves
retrograde wrapping of a 1/2 Penrose drain
and securing the drain at the base of the
finger. This tourniquet is bulky and very
unlikely to be left in place underneath a
bandage following the procedure.

Digital Block Healing by Secondary Intention

Many procedures can be performed in an
emergency-room setting. A digital block
provides a quick and effective option to
anesthetize the injured digit3. Although
epinephrine historically has been avoided
because of a theoretical risk of vasospasm-
Irrigation, debridement, and local wound
management often represent sufficient
treatment of fingertip soft-tissue defects. If
bone is not exposed and the soft-tissue
defect is ,1.5 cm, the wound can be
cleaned and debrided in the emergency

COPYRIGHT © 2020 BY THE Disclosure: The authors indicated that no external funding was received for any aspect of this work.
JOURNAL OF BONE AND JOINT The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the
SURGERY, INCORPORATED article (http://links.lww.com/JBJSREV/A581).

JBJS REVIEWS 2020;8(4):e0182 · http://dx.doi.org/10.2106/JBJS.RVW.19.00182 1

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room and allowed to heal by secondary
intention with the use of daily semi-
occlusive dressing changes5,6. The
patient should be encouraged to use the
affected hand without the need for pro-
longed immobilization of the affected
digit2. In a review of secondary healing
of fingertip injuries, Krauss and La-
londe7 noted that allowing wounds to
heal by secondary intention has been
shown to decrease time missed from
work while also avoiding the donor-site
morbidity and immobilization associ-
ated with flap procedures. The authors
also reported that the average time to
healing was 4 weeks, with ,1 week
missed from work. Although not infre-
quently reported, cold intolerance was
usually resolved by 1 year post-injury.
Nail deformities such as hook nail or
parrot-beak deformity occurred in 6%
of the 1,592 patients included in the
review, but Krauss and Lalonde found
that most patients considered the aes-
thetic results to be good. They also noted
few infections and no osteomyelitis.
Nail-Bed Repair
Fingertip injuries often result in injuries
to the nail bed, which if left untreated
can result in nail deformity. Although a
nail-bed injury is usually evident if the
nail itself is injured, nail-bed repair is
reportedly required in 60% of cases of
subungual hematoma affecting at least
half of the nail. This statistic rises to nearly
95% if the hematoma is associated with a
distal phalangeal fracture8. Occasionally,
trephination of the hard nail with an 18-G
needle is sufficient to relieve discomfort,
but nail-bed repair is often required.
When a nail-bed laceration repair is
indicated, the hard nail should carefully be
removed and the wound should be thor-
oughly irrigated and debrided. Although
we prefer repair with fine absorbable
chromic sutures, 2-octylcyanoacrylate
glue can be used with equivalent results5.
Primary Closure
When partial fingertip amputations
have inadequate tissue for replantation
or have exposed bone, revision ampu-
tation is the most commonly employed
surgical technique. Although amputa-
tion requires some loss of digital length,
early mobilization is also usually al-
lowed5. Generally, a digital block is
performed in the emergency room and
the wound is debrided. The bone is
shortened with a rongeur, and the
wound is closed with fine absorbable
sutures1,5. Digital nerves should be re-
sected to a level that is proximal to the
anticipated line of wound closure. In a
single-institution review of 537 patients
with 677 injured digits, Harris et al.1
reported a 13.8% rate of complications,
most commonly soft-tissue necrosis,
painful neuroma, and nail deformity.
Infection occurred in ,1% of cases.
Work-related injuries and injuries to the
index finger showed increased rates of
reoperation.
Local Flaps for
Digital Reconstruction
When replantation is not possible, local
or regional flap reconstruction can be a
useful alternative to gain early soft-tissue
coverage and allow more functional
rehabilitation6.
Fingertip Reconstruction
V-Y Advancement Flap
Primarily utilized in transverse or
oblique dorsal fingertip amputations,
often through the distal or middle pha-
lanx, the V-Y advancement flap allows
for satisfactory contour and sensation
without the need for postoperative
immobilization (Fig. 1)9. A V-shaped, or
inverted triangle, incision is created with
the apex proximal, taking care to incise
the skin without damaging the under-
lying neurovascular structures. When

Fig. 1
Figs. 1-A, 1-B, and 1-C V-Y advancement flap for a transverse fingertip amputation with exposed bone. Fig. 1-A The injured digit is prepared and
draped with the V-shaped incision marked on the skin. Fig. 1-B The incision has been made and the surgeon begins to mobilize the flap. With distal
traction on the flap, it is advanced by releasing the more proximal fibrous septae in the pulp of the fingertip with a spreading technique. Fig. 1-C The
flap is sufficiently mobilized to cover the defect and is loosely sutured in a V-Y configuration.

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deep to the dermis, subcutaneous fat will
be visible; the dissection is stopped at
this depth to protect the neurovascular
structures. Atasoy et al.9 suggested that
for more distal phalangeal amputations,
the apex should be at the distal flexion
crease to allow for the longest flap pos-
sible. After incising the flap, traction is
applied distally using a small hook or
suture. Proximally, fibrous septae are
released to allow the flap to be advanced
into position, where the flap is secured
with absorbable sutures. The initial
V-shaped incision on the palmar side is
closed to create the “Y.”
Thoma and Vartija10 emphasized
the need for a tension-free closure to
avoid necrosis in the advanced flap. The
authors modified the initial Atasoy tech-
nique to reduce tension by only closing the
base of the triangle, allowing the donor-site
defect to heal by secondary intention. The
initial dressing is removed 3 to 5 days
postoperatively, and daily saline solution
baths are initiated. Thoma and Vartija
noted complete healing by 10 to 12 days.
Cross-Finger Flap
The cross-finger flap is an option for
providing soft-tissue coverage for volar
oblique fingertip injuries. The donor
flap is raised on the dorsal aspect of the
adjacent digit, extending from the
proximal interphalangeal joint to the
distal interphalangeal joint. The depth
of the dissection should be in the plane
between the extensor tendon paratenon
and the subcutaneous tissue. Panattoni
et al.6 emphasized that the transverse
nature of this flap ensures the inclusion
of the dorsal branch of the proper digital
artery in the flap, allowing for adequate
perfusion. The hinge of the flap is on the
side adjacent to the recipient digit. The
flap is mobilized to cover the volar defect
on the adjacent digit and sutured in
place. The donor site can be covered
by a full-thickness skin graft from the
medial aspect of the forearm. Release of
the Cleland ligaments, just dorsal to
the neurovascular bundle, relieves ten-
sion and improves flap mobility. The
flap can be divided at about 15 days
postoperatively5,6,11. In a retrospective
review of 28 patients who underwent a
cross-finger flap for fingertip injury at a
single center, Rabarin et al.11 reported
that none of the patients experienced
necrosis or neuroma symptoms. All
patients regained sensation in the
affected fingertip, with less than half of
patients experiencing mildly altered
sensitivity. Cold sensitivity was the most
common complication, occurring in
25% of the patients. Importantly, there
were no cases of flexion deformities or
donor-site morbidity. The authors
emphasized the importance of carefully
creating a thick flap deep to the subcu-
taneous tissue to prevent necrosis.
Radiographs were utilized to compare
the pulp depth in the healed surgically
treated finger compared with the con-
tralateral uninjured finger, and a mean
ratio of 1.03 was found. A patient-
reported visual analog scale of 0 to 10
confirmed overall patient satisfaction
with the appearance, as the average score
was 9.2. Although this procedure is
generally reliable, donor-site morbidity
including potential donor finger pain,
grip-strength weakness, or cold intoler-
ance can occur and should be discussed
with the patient preoperatively and fac-
tored into patient expectations12.
Reverse Cross-Finger Flap
The reverse cross-finger flap is techni-
cally difficult but ideal for covering full-
thickness dorsal finger wounds (Fig. 2).
Indications include dorsal wounds to the
eponychial fold or sterile matrix with
exposed extensor tendon or bone. This

Fig. 2
Figs. 2-A, 2-B, and 2-C Reverse cross-finger flap for a dorsal finger defect. Fig. 2-A A soft-tissue defect is present on the dorsal surface of the ring finger
over the middle phalanx with exposed tendon. The incision for a reverse cross-finger flap has been made on the adjacent finger. The full-thickness skin
flap is raised to the level of the dermis. The hinge of this skin flap is on the side furthest from the injured digit. Fig. 2-B A subcutaneous flap is raised in
the opposite direction to the level of the extensor tendon paratenon with the hinge on the side nearest the injured digit. Fig. 2-C Only the dorsal fat
and subcutaneous tissue are used to cover the defect and sutured in place. The initial skin flap is sutured in place to cover the donor site. The recipient
site can then be covered with a full-thickness skin graft.

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Fig. 3
Figs. 3-A, 3-B, and 3-C Antegrade homodigital island flap for a volar finger soft-tissue defect with exposed tendon and bone. Fig. 3-A The desired
pedicle has been outlined on the radial or ulnar side of the digit overlying the neurovascular bundle. A mid-lateral incision is made extending proximal
to the pedicle. Fig. 3-B The pedicle flap then is dissected from the volar side down to the flexor sheath. The flap is raised off the flexor tendon sheath
and the pedicle is dissected proximally. The neurovascular bundle is dissected and released of surrounding structures. It is important to confirm that
the neurovascular structures are indeed running into the planned flap. Fig. 3-C The flap is advanced to cover the defect and is loosely sutured in place.
The donor site can be covered with a full-thickness skin graft and the remaining defect closed loosely in a “Y” fashion.

technique can also be used during repair
of boutonniere deformity with inade-
quate dorsal skin, but cannot be used if
the dorsal skin on the potential donor
digits is inadequate. Atasoy recom-
mended raising a flap on the dorsum of
the middle phalanx that is about 1 cm
longer and 0.5 cm wider than the
defect on the adjacent digit13. The full-
thickness skin flap is raised at the level of
the dermis. The hinge of this skin flap is
on the side furthest from the adjacent
injured digit. Next, a subcutaneous flap
is raised in the opposite direction to the
level of the extensor tendon paratenon
with the hinge on the side nearest the
injured digit. Only the dorsal fat and
subcutaneous tissue are used to the cover
the defect. The initial skin flap is sutured
to cover the donor site, and the subcu-
taneous flap is sutured in place, covering
the recipient site. The recipient site is
covered with a full-thickness skin graft,
which can be harvested as a pinch graft
from the forearm13. As mentioned for
the cross-finger flap, donor-site mor-
bidity should be discussed with the
patient12.
Antegrade Homodigital Island Flap
The antegrade homodigital island flap
is an option for restoring soft-tissue
coverage as well as sensation to injured
fingers with pulp loss and possibly
underlying fracture14. This flap relies on
a neurovascular bundle from the same
digit (Fig. 3)2. Advantages include the
need for only a single-stage surgical
procedure, the benefit of avoiding
donor-site morbidity associated with
transferring tissue from adjacent fingers,
and maintained digit length. In 2013,
Katz14 detailed the surgical technique
for this flap. Once the desired pedicle has
been outlined on the radial or ulnar side
of the digit overlying the neurovascular
bundle proximal to the distal interpha-
langeal joint, a mid-lateral incision is
made dorsal to the pedicle. The bundle is
then dissected and released surrounding
structures, including the Cleland and
Grayson ligaments. It is critical to con-
firm that the neurovascular structures
are indeed running into the planned
flap. The nerve and artery are not sepa-
rated, and a small amount of tissue is left
around the bundle in order to preserve
venous outflow15,16. The pedicle for the
flap is then dissected from the volar side
down to the flexor sheath. The dissec-
tion may also start with this volar aspect
of the flap prior to proceeding proxi-
mally along the finger. The flap is raised
off the flexor tendon sheath, and the
pedicle is dissected proximally to a
level that allows sufficient advancement
to reach the defect. If necessary, dissec-
tion can be carried out proximal to the
metacarpophalangeal joint to achieve
sufficient mobilization. If further
advancement is desired, the interpha-
langeal joints can be flexed slightly.
Proximal interphalangeal joint contrac-
ture is possible but is usually very mild.
Once the flap is advanced into the
defect, it can be loosely secured with
interrupted absorbable sutures14. The
donor site can be covered with a full-
thickness skin graft, and the remaining
defect can be loosely closed in a “Y”
fashion2,14. Aydin et al. retrospectively
compared the outcomes from the ho-
modigital island flap to the cross-finger
flap in 25 patients, showing that the
homodigital island flap resulted in better

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Fig. 4
Figs. 4-A through 4-D Reverse homodigital island flap for a volar middle finger soft-tissue defect. Fig. 4-A After performing a digital Allen test, the
planned flap and incision are marked. Fig. 4-B The initial incision has been made, starting at the volar margin of the planned flap. The surgeon
mobilizes the flap, and the proximal neurovascular structures are located running into the planned flap. Taking care to stay volar to the artery in order
to protect the soft tissue attachments to the flap, the nerve can be carefully dissected free from the artery. The nerve is seen here running along the
volar side of the donor site. Fig. 4-C The incision is carried distally to the middle of the middle phalanx, and the nerve is carefully separated, taking care
not to injure the artery or nerve. Fig. 4-D The flap is rotated to cover the defect and sutured in place. A full-thickness skin graft is used to cover the donor
site.

2-point discrimination and range of
motion at the distal interphalangeal joint17.
Retrograde Homodigital Island Flap
For larger defects, a reverse homodigital
island pedicle flap can be utilized
(Fig. 4). As the name implies, the pedicle
relies on the retrograde flow from the
digital anastomosis of radial and ulnar
blood flow. In the middle finger, the flap
is ideally taken from the ulnar side of the
digit. The radial side of the digit is used
to harvest a flap in the ring and small
fingers18. Germann et al.2 suggested that
this technique should not be used for the
dominant hand or for the index finger or
thumb, citing limited recovery of
sensation.
A digital Allen test should be per-
formed preoperatively to ensure that
both digital arteries adequately perfuse
the digit. The flap can be marked along
the border of the proximal phalanx. The
incision begins with the volar margin of
the flap. The neurovascular bundle is
identified proximally running into the
flap. The digital nerve can be carefully
dissected off the artery by elevating the
nerve in a volar direction with use of a
spreading technique. Maintaining the
soft-tissue connections between the artery
and the flap preserves the venae com-
itantes. The involved digital artery is
ligated proximally to the flap. The dis-
section is carried distally by dissecting the
pedicle to the midpoint of the middle
phalanx, carefully separating the nerve.
Once adequate flap and pedicle mobili-
zation is achieved, the flap can be rotated
to cover the defect. The flap is sutured
loosely in place, and the incisions are
closed2,18,19. A full-thickness skin graft
can cover the donor site. As an alternative
technique, the nerve can be cut at the
time the artery is ligated. The proximal
stump can be buried in the tissue to
prevent formation of a neuroma, and
the distal end can be sutured to the re-
maining contralateral digital nerve to the
pulp20.
In a review including 207 patients
with 230 injured digits, Regmi et al.21
noted higher success rates and sensation
similar to those reported for replanta-
tion. The authors noted a rate of com-
plete flap necrosis of only 2%, with a 5%
rate of partial necrosis. Other compli-
cations included cold intolerance
(12%), venous congestion (4%), and
flexion contracture (4%).

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Fig. 5
Figs. 5-A, 5-B, and 5-C Moberg advancement flap for a volar thumb soft-tissue defect. Fig. 5-A A mid-axial incision is marked on the skin on the radial
side of the thumb. The incision on the ulnar side of the thumb mirrors this incision. Fig. 5-B The surgeon uses a spreading dissection technique to
release connecting structures, allowing flap mobilization. The neurovascular bundles are included in the flap. The flap is completely released distally
and remains attached proximally. Fig. 5-C The flap is advanced to achieve adequate coverage of the defect with minimal tension and sutured in place.
The closure on the ulnar side mirrors this repair.

Heterodigital Island Flap
The surgeon may elect to use a hetero-
digital island flap to cover volar or dorsal
finger defects when the homodigital
island flap is not an option, such as when
the adjacent tissue or the desired flap
itself is damaged. If there is concern for a
palmar injury that may compromise the
pedicle vessel, this flap technique should
not be utilized. Similarly, chronic vessel
damage from smoking or vascular dis-
ease should urge the surgeon to choose
an alternative procedure. Pham and
Netscher22 provided a technical guide to
the procedure, detailing the intra-
operative steps to surgical planning and
pedicle flap dissection and transfer. The
authors suggested first templating the
defect and tracing the proposed donor
flap on the adjacent digit. The tourni-
quet is inflated, and the flap is first ele-
vated off the volar surface of the flexor
tendon sheath, and the pedicle is traced
proximally. The digital artery is dis-
sected free from the nerve, and the nerve
is left in situ to preserve sensation dis-
tally. The pedicle is dissected proximally
to the bifurcation from the common
digital artery. The dorsal digital nerve
can also be dissected proximally and
microsurgically repaired to promote flap
sensation. The flap is loosely secured
to the recipient site with absorbable
sutures, and the donor site is covered in
the usual manner with a full-thickness
skin graft23. Limited studies are available
to describe the details of successes or
complications of this procedure.
Thumb Reconstruction
Thumb-tip injuries are uniquely chal-
lenging, and several surgical procedures
are viable choices to cover the wound
and provide satisfactory function and
appearance24.
Moberg Advancement Volar Flap
When traumatic injury leaves a volar
pulp wound measuring #2 cm, the
Moberg advancement flap should be
considered to cover the wound while
restoring function and sensation
(Fig. 5)25. Mid-lateral incisions are
made on the radial and ulnar sides of
the thumb, and the volar flap is care-
fully raised off the flexor tendon. Once
mobilized, the flap can be advanced to
cover the defect distally and sutured
into place2,5,24-26. Macht and Wat-
son26 emphasized a spreading tech-
nique in order to preserve blood
supply, minimize dissection, and
ensure adequate mobilization. Only
the distal end of the flap is completely
incised. Full thumb motion is started at
1 week postoperatively, and new flex-
ion creases ultimately develop.
Baumeister et al.27 studied 36
patients who underwent Moberg flap
advancement for thumb reconstruction
for defects ranging from 1 to 3 cm. In
order to cover larger defects, modifica-
tions such as Z-plasty or V-Y modifica-
tion were implemented. In 83% of the
patients, no bone shortening was nec-
essary. All flaps survived, and 74% of
patients reported normal sensation as
measured by monofilament sensitivity
testing. Without bone shortening, there
was no significant effect reported on grip
strength, and range of motion testing
revealed only a minor loss of full exten-
sion of the thumb in some patients.
Complications were reported in 31% of

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patients, including infection (17%) and
superficial necrosis or epidermolysis
(17%). Foucher et al.28 reviewed 7
patients who underwent Moberg flap
procedures, and reported overall satis-
factory results with good sensation and
range of motion, with most noting cold
intolerance and a few noting nail defor-
mity or pulp instability.
Homodigital Island Pedicle Flaps
Homodigital island pedicle flaps depend
on the reliable thumb neurovascular
anatomy to cover distal thumb defects.
One option is a pedicle based on the
dorsal radial artery, which is a branch of
the radial artery arising at the level of the
anatomic snuffbox. An anatomic study
by Moschella et al.29 showed that the
dorsal radial artery courses under the
extensor pollicis brevis before running
along the radial side of the thumb. After
identifying the artery with Doppler
ultrasonography and drawing the
desired flap, the pedicle flap is raised
proximally to distally, taking care to stop
the dissection at the middle of the
proximal phalanx in order to protect the
palmar vessel anastomoses. The sensory
collateral nerve branch of the radial
nerve is also included in the flap, which
aids in sensation. The flap can then be
rotated and sutured in place24,30. The
donor defect can either be closed or
covered with a full-thickness skin graft,
depending on the size of the defect. Sun
et al.31 showed that this flap can achieve
good sensation (particularly for smaller
flaps) and noted that encouraging post-
operative functional exercises can
potentially increase sensation.
The anatomy of the dorsoulnar
collateral artery provides another similar
option for thumb-defect coverage. As
Brunelli32 described, the dorsal ulnar
artery of the thumb and dorsal radial
artery of the index finger converge over
the ulnar aspect of the metacarpal head
of the thumb. Once the pedicle is iden-
tified by Doppler ultrasonography, the
flap can be raised, and the defect can be
covered in much the same manner as the
Moschella dorsal radial artery flap
described above24. The results of
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this flap for soft-tissue coverage are
promising, but recovery of sensation is
variable33,34.
First Dorsal Metacarpal Artery Flap
The first dorsal metacarpal artery flap,
also known as the kite flap, is a useful
option for the coverage of dorsal thumb
defects24. This sensate skin flap is
donated from the dorsum of the proxi-
mal index finger and receives its inner-
vation from the superficial branch of the
radial nerve. In an anatomic study of 18
hands, Sherif reported that all patients
had a constant cutaneous branch of the
first dorsal metacarpal artery deep to
the subcutaneous veins35. A Doppler
ultrasonogram is utilized to locate the
first dorsal metacarpal artery prior to
incision. The flap is drawn to match
the defect, with the planned pivot
point being the base of the index
metacarpal36,37. A dorsal S-shaped
incision is made over the first web
space, and dissection is carried down to
include the aponeurosis of the first
dorsal interosseus muscle in the pedi-
cle. The radial aspect of the flap is
harvested next, with care to protect the
pedicle. The remainder of the flap is
then raised off the extensor peri-
tenon38. The subcutaneous veins
should be carefully protected to maxi-
mize venous outflow from the flap24. A
subcutaneous tunnel can be utilized to
move the flap to the defect. The flap is
then sutured in place to cover the
defect. The donor site is covered with a
full-thickness skin graft36.
In a study of 11 patients who
underwent a modified first dorsal met-
acarpal artery flap for thumb injuries,
Chen et al.37 reported 100% flap sur-
vival and donor site healing. Patients
were either “strongly satisfied” or “sat-
isfied,” with range of motion reaching
.95% of the contralateral side and
sensation reaching 72% to 75% of that
side.
Pediatric Considerations
The most common mechanism of injury
in the pediatric population is crush, such
as from a car or house door. Sports
Tr e a t m e n t o f F i n g e r t i p I n j u r i e s |
injuries increase in frequency in older
children39,40. Children often present
with fractures, nail-bed injuries, or
complete or partial amputations.
Open injury to the distal aspect of the
finger requires local wound care and often
antibiotic administration. Although the
use of prophylactic antibiotics for patients
with fingertip injuries is generally com-
mon practice, there is no standard proto-
col; however, in a study of 146 pediatric
patients with fingertip injuries who
received either prophylactic oral cepha-
lexin or no antibiotic, Altergott et al.41
reported no difference in infection rates.
Nail-bed repair and fracture
reduction and stabilization represent
adequate care for most injuries to the
distal part of the finger5. Although
complete soft-tissue coverage is ideal,
pediatric fingertip injuries often do well
functionally and cosmetically when
treated by nonoperative means, even if
there is some bone exposed42. It is
important to recognize that in the
pediatric population, the nail matrix can
potentially be trapped in the growth
plate. This injury pattern, known as a
Seymour fracture, must be addressed at
the time of the surgical procedure5. One
unique treatment option in children
with partial amputation injuries distal to
the distal interphalangeal joint is com-
posite grafting. When it is not possible
anatomically or logistically to perform a
formal replantation, composite grafting
allows for an immediate repair in either
the operating or emergency room. This
technique involves reattachment of the
amputated skin and soft tissue without
microvascular anastomosis. The ampu-
tated skin is cleaned, defatted with use of
curved sharp scissors, and sutured into
position with fine absorbable sutures39.
If a fracture is present and adequate
stability is not obtained by composite
grafting alone, a Kirschner wire may be
used for added fixation5. In a study of 39
patients with a mean age of 5.9 years who
underwent composite grafting, Eberlin
et al.39 noted that only 3 patients (7.7%)
had a complete graft take, whereas 23
(59.0%) partially took and 13 (33.3%)
did not take. Although a prior study
7
 | Tr e a t m e n t o f F i n g e r t i p I n j u r i e s
suggested that composite grafting
done within 5 hours of injury yielded
a significantly higher success rate,
Eberlin et al. separated patients who had
a delayed presentation and found no
difference in graft take. The authors
attributed this lack of difference to the
fact that skin and fat do not suffer the
same level of irreversible ischemic dam-
age as does muscle during that 5-hour
window39. In that study, 1 of the
patients who had failure of composite
grafting underwent revision amputation
and another underwent a debridement
and V-Y advancement to close the
defect. Therefore, the soft-tissue strate-
gies described below for the adult pop-
ulation should still be in the toolbox of
the pediatric hand surgeon. Haehnel
et al.43 studied the long-term outcomes
of the V-Y advancement flap in 47 chil-
dren, noting no infections or flap necrosis,
with normal distal interphalangeal range
of motion in all patients; however, the
appearance was not ideal, with several
patients reporting nail and pulp shape
abnormalities, as well as cold sensitivity
and pain43. For more severe defects, the-
nar flaps may also be considered in the
pediatric population, as these patients are
less likely to experience the common
complications such as contracture or
donor-site morbidity44.
Conclusions
The treatment of soft-tissue defects with
possible exposed bone following finger-
tip or thumb-tip injuries requires careful
surgical planning and execution to pro-
vide the best outcome for the patient.
Management ranges from nonoperative
treatment to a variety of surgical options.
In addition to considering the location
and orientation of the injury, the phy-
sician must consider other factors
such as associated injuries, the ability or
desire of the patient to comply with
postoperative instructions, the need
for immobilization, and medical
comorbidities.
Thomas M. Neustein, MD1,
Samuel H. Payne Jr., MD2,
John G. Seiler III, MD2
8 APRIL 2020
1Department
of Orthopaedic Surgery,
Emory University School of Medicine,
Atlanta, Georgia
2Georgia Hand, Shoulder, and Elbow,
Atlanta, Georgia
Email address for T.M. Neustein:
tneuste@emory.edu
ORCID iD for T.M. Neustein:
0000-0003-2797-7228
ORCID iD for S.H. Payne Jr.:
0000-0002-8351-1994
ORCID iD for J.G. Seiler III:
0000-0002-4079-4680
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