Finger Tip Injuries

Presented by: Nadeem Al-Jundi,PGY4

Moderated by Dr.Bareqa Salah
Introduction
 Fingertip injuries are the most common type of
upper extremity trauma.

 50% at the distal phalanx.

 Occur to patients of all ages.

 Most often seen in working men.

Introduction
 Successful repair of fingertip injuries requires..

 knowledge of anatomy.
 knowledge of the techniques of reconstruction.
 Appropriate surgical judgment.
History – Key historical elements include:
•Age and skeletal maturity
•Mechanism and time of injury
•Digit position during injury (flexed versus extended)
•Dominant hand
•Occupation
•Prior hand conditions, injuries, or interventions
Physical examination – The clinician should determine the
extent of damage to the nail, nail folds, nail bed, and germinal
matrix by inspection and evaluate for associated proximal
injuries to the finger or hand by testing neurovascular status and
range of motion.

**Findings of nail bed laceration include subungual hematoma

**Vascular examination(pallor, capillary refill).

**Neurological examination: “two-point discrimination”
Indirect evidence of intact sensory innervation is obtained by placing the finger in a bowl
of warm water for five minutes. Intact innervation is indicated by wrinkling of the skin of
the distal finger, whereas nerve injury results in persistence of smooth skin.

**The detailed evaluation of range of motion of the finger and

detection of fractures and dislocations.
Preoperative X-ray PA and lateral views to assess:

1)Distal phalangeal fractures

2)The presence of a foreign body.
 subungual hematoma
 Treatment depends on the size of the hematoma.
 A small subungual hematoma (< 50% of the nail surface)
usually heals on its own
 the pressure of the blood under the nail can be extremely
painful
 Drainage by heat the tip of a needle until it is red hot. Then use
it to puncture the nail, and let the accumulated blood escape
Drainage of subungual hematoma
 subungual hematoma
 It is blood clot under the nail
 subungual hematoma
 In patients with a large hematoma, (≥ 50% of the
nail surface)
 the usual recommendation is to remove the nail.
 Often there is a significant laceration in the nail bed
Nail bed injury and repair
Protect the repaired nail bed by splinting with the original nail, if
possible:
•Gently clean the nail in a dilute solution of normal saline.
•Place a large hole, 3 to 4 mm in diameter, in the center of the nail
using a sterile needle to allow drainage.
•Replace the nail beneath the proximal fold.
Although silicone splints are available, a retrospective analysis of
complications after nail splinting with native nail versus silicone nail
revealed significantly fewer nail deformities when the native nail
was replaced compared with splinting with a silicone product
outcomes.
•If the original nail cannot be used, place a nonadherent splint
consisting of a single thickness of nonadherent sterile gauze
, 0.20 inch reinforced silicon sheeting, or sterile foil from the
suture packet in the proximal fold and suture in place through the
lateral skin folds using absorbable 4-0 suture or use skin glue .
●Apply a protective dressing consisting of a layer of sterile
petrolatum-impregnated gauze (eg, Vaseline gauze) covered with
sterile dry gauze or a silicone net dressing . Then place a finger
splint.
Finger Tip Injury with no soft-tissue loss

 simple closure is all that is needed .

 Viable skin flaps are loosely sutured.
 and a splint is applied if a fracture is present
GENERAL PRINCIPLES
Line A: can be skin
grafted or allowed to heal
by secondary intention.

Line C (Guillotine
amputations): best
treated by bone shortening
and primary closure or
with local advancement
flaps.
GENERAL PRINCIPLES
Line B (Volarly
directed amputations):
may require regional flap
coverage such as a cross
finger flap.
Line D (dorsally
directed amputations):
closed primarily following
bone shortening and
residual nail ablation.
Partial fingertip skin avulsion – These injuries
may be repaired with absorbable suture (eg, 5-0
vicryl) using simple interrupted stitches .
Full fingertip skin avulsion – The approach to these injuries is determined
by the size of the defect, whether the amputated tissue is available, and the age of
the patient:

•Defect <1 cm – Allow the injury to granulate or, if available, suture the cleaned
and defatted amputated tissue in place with absorbable suture (eg, 5-0 chromic)
and simple interrupted stitches

•Defect >1 cm – If the amputated tissue is available, clean and defat it and then
suture it in place with absorbable suture (eg, 5-0 chromic) using simple
interrupted stitches.

•If the amputated tissue is not available, but the patient is under two years of age,
the wound may simply be dressed and allowed to granulate.
Local Flap Coverage

 Used to cover digital amputation stumps with

exposed bone.

 Seek to preserve length and provide soft tissue

coverage of similar quality to that of normal.
Local Flap Coverage
 Kutler Lateral V-Y Flaps:
 Cut from the sides of the injured digit and advanced
distally to cover the amputated tip.

 The distal nail bed is approximated to the dorsal flap

edges and the donor defects are closed in a Y
bilaterally.
Local Flap Coverage
 Volar V-Y Flap:
 Best suited for transverse midnail or dorsally directed tip
amputations.

 The wound is debrided and the bone end smoothed.

 Complications:
 Flap necrosis at the distal end.
 Curved nail deformity.
 Dysesthesia.
 Cold intolerance.
Local Flap Coverage
 Volar Advancement Flap:
 Although described for all digits, is probably best used
in selected thumb tip amputations.
 The flap in all cases can be advanced only about 1 cm.
 Complications:
 Flap necrosis.
 Cold intolerance.
 Residual digital stiffness
COMPOSITE AMPUTATIONS

 Complete guillotine amputation  replace the

amputated part as the composite graft in children
<6 years of life.
Local Flap Coverage
 Cross Finger Flaps:
 Volarly directed tip amputations with an exposed distal
phalanx and insufficient local tissue for flap coverage.
 Cross finger flaps are divided across the base in 14 to
21 days.
 Complications:
 Residual joint stiffness.
 Donor site depression and pigmentation changes.
Local Flap Coverage
 Side Cross Finger Flap:
 Provides excellent coverage for thumbtip amputstions
in patients of all ages.

 Minimizes the cosmetic donor site deformity.

Local Flap Coverage
 Thenar Flap:
 Employs a proximally or distally based flap elevated
off the muscles of the thenar eminence.

 Later modified with an H-shaped thenar incision,

creating proximally and distally based flaps.

 Residual digital stiffness is a possible complication of

all thenar flap techniques.
DORSAL DIGITAL INJURIES
 Dorsal digital avulsion injuries involving multiple
fingers with exposed tendon or bone stripped of
perivascular connective tissue, or with open joint
surfaces, cannot be covered by a skin graft.

 Types of repair:
 Distant Pedicle Flap; from the chest, abdomen, groin, or opposite arm .
 Upside Down Cross Finger Flap.
 Arterialized Side Finger Flap.
DORSAL DIGITAL INJURIES
 Distant pedicle flap:
 From the chest, abdomen, groin, or opposite arm.
 When large areas of dorsal loss have occurred.
 Disadvantages:
 prolonged hand and extremity immobilization.
 bulkiness of the fIap.
 digital and/or extremity stiffness.
 multiple surgical procedures.
 poor return of fIap sensibility.
DORSAL DIGITAL INJURIES
 Upside Down Cross Finger Flap:
 For less extensive dorsal digital avulsion injuries.
 Complications:
 incomplete skin graft take.
 noticeable donor site deformity.
 digital stiffness.
 inclusion cyst formation.
 Wound care and patient instructions :

1..leave the dressing and, if applicable, the finger splint in place until
the follow-up visit

2.. Elevation of the hand above the heart

3.. oral nonsteroidal antiinflammatory medications (eg, ibuprofen)

4.. Excessive soiling of the dressing, hemorrhage, fever, redness

extending up the finger, or marked dorsal hand swelling are
indications for emergent reevaluation
COMPLICATIONS :

●Abnormal nail growth – Normal nail growth following a

nail bed laceration requires a smooth nail bed. Extensive injury or
failure to precisely approximate the nail bed may result in an
irregular contour of or a nonadherent nail.

Meticulous repair of the nail bed with careful approximation of

the nail folds, minimal debridement of the nail bed, and use of the
minimum number of sutures to adequately close the nail bed
wound serve to minimize these undesirable cosmetic outcomes.
●Wound infection – The reported infection rate after
hand and fingertip injuries is approximately 6 percent .

Careful wound debridement and irrigation are most

important in preventing this complication.

*** Prophylactic antibiotics do not significantly alter

the rate of infection in healthy patients with minimally
contaminated wounds.
Thank You