Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous...
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Fingertip Injuries
Anthony PereraAndy Mahon
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Nail Bed Anatomy
Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity (2pt discrimiantion reduce without it to acts a counterforce)
Paronychium
Hyponychium –
Sterile Matrix-adheres to the nail by adding squamous epithelial cells to the advancing nail, making it thicker, stronger and more adherent. Attached to periosteum
Germinal Matrix –gradient perkeratosis -3mm/month
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Surgical AnatomyGerminal matrix
–distal extent of lunula, ave. distance to end of Extensor is 1.2mm thus care, but if you see the extensor then you have cleared the whole of it.
Dorsal nail fold – 10% of nail growth (and shine) thus can get spicules, need to prevent it sticking down.
Sterile matrix- if not accurately reduced get abnormal nail.
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Fingertip Injuries
• Subungual haematoma
• Nail bed laceration• Distal phalanx fracture• DIPJ dislocation• Mallet finger• FDP rupture
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Subungual Haematomas
If >25 % of nail then risk of nail bed injury
If >50% high risk of significant injury
Thus >25% -trephine>50% and high energy –
remove nail and inspect nail bed
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Nail Bed Injury Classification
I -Small haematoma (>25%)II -Large haematoma (>50%)III -Laceration + FractureIV -Nail bed FragmentationV -Nail bed Avulsion
+/- paronychium+/- whether it involves S or G
matrix
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Nail Bed Injury Management
REQUIRES NAIL REMOVAL If-haematoma >25%
(Zook and Brown)
-#-dorsal nail fold or
paronychyia disrupted -Avulsed nail
Not in children (Roser J Hand Surg 99 –RCT)
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Principles of Operative Management
1. Remove nail2. Reduce and fix # 1st(K wire
or figure of 8 suture) 3. Open corners of dorsal nail
fold to improve view4. Replace all of nail bed and
accurately repair5. When all nail bed not
available consider grafting6. Clean nail and replace ( or
use foil packet)7. Either trephine or use glue8. Repair dorsal fold (or
appropriate graft)
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How to Deal With Tissue Loss
Sterile Matrix-ST graft,v thin so no donor site deformity-take 1-2mm more than needed – it contracts-Place in same axis-If periosteum stripped–decorticate bone
Germinal Matrix-can do rotation flaps if small-if >1/3 can take from toes ( S or FT)- not as good–both sites get deformity
Dorsal Nail Fold-rotation flap - ? Put ST sterile matrix graft on undersurface
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Post –Op ManagementDressing 7-10 dys –protect nailStart desensitsation at 2/52Move immediatel unless #K wire out at 4/52New nail pushes old one out at 2-3 weeks
Complications• Non-adherence or ridging of plate• Split nail• Crooked nail plate• Hooked nail
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Dealing With Complications
1. Non-adherence/ ridgingDue to granulation tissue from poor repair of nail bedRx –scar excision
2. Split NailDue to longitudinal scar in matrixRx –excise and graftDue to adhesionsRx –graft and stent apart
3. Crooked Nail PlateDue to sterile matrix contracture on 1 sideRx –excise and full thickness graft
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Dealing With Complications
4. Hooked NailDue to insufficient bony supportRx – AVOID, don’t use nail bed to cover partial amputationDistal edge of sterile matrix should be at least 2mm from distal edge of bonecan shorten nail bed or release it distally to allow retraction proximally
If uncorrectable nail deformity -can fully excise and use full thickness skin graft
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Fingertip Injuries
Goals of Treatment1. Preserve Function2. Durable coverage3. Preserve useful sensibility4. Prevent symptomatic neuromas5. Prevent joint contracture6. Shorten recovery7. Reduce morbidity8. Preserve length –especially thumb
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Fingertip Injury Classification
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Management
Type I Primary ClosureSecondary healingComposite graftsSplit thickness skin graft
Type II Shorten and closeCoverage
Type III Amputation
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Type I -1O Closure + 2O Healing
Equivalent Results
Primary – if no tension
Secondary – if <1cm and no exposed bone, volar cuts
?pulls in innervated tissue
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Conservative Management
• Patients / parents may need convincing
• Some doctors too!• Before and after pictures of example
cases• Particularly in children• Das, Brown 1978
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Type I -Composite GraftsChildren – at mid-level or distal to nail bed. Need to explain will scab off.Rose – near normal appearance, 2 pt 6.5mm, no infections
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Type I- 2OHealing vs Grafting
Holm and Zachariae- 5 year FU2O STSG
Good 90% 50%Cold Sens 39% 33%Dec Sens 26% 67%Pain at Site 71%Return to work IncComplications Inc
Mennem and WieseEven if bone exposed near normal shape, useful epithelium,
no complications, no hook nail, excellent sens
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Type II
1. Shorten and conservative2. Shorten and close, see at 2-3 days
? AntibioticsManual labourers- return to work 6-8 weeksIf not enough bone then trim nail bed back to avoid hook nail.
3. If important to preserve length – need coverage
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Type II- Coverage
1. Atasoy-Kleinert Volar V-Yplasty
2. Kutler Lateral V-Y flaps
3. Moberg Volar flap Advancement
4. Cross-finger Pedicle flap
5. Neurovascular Island Flaps
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Advancement Flaps
• Nice technical exercises!• Preserve length• Originators results seem better than
others
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Atasoy-Kleinert V-Yplasty
• Nail bed and pulp with exposed bone (CI –if loss palmar >dorsal)
• Apex of triangle at DIP
Problems ( Atasoy 56/61 normal sens +
ROM)70% hypo-dyaesthesia40% cold sens50% difficulty with grasping
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Kutler Lateral V-Y plasty
• Transverse amputation• Useful in dorsal oblique
Problems– If too large can get
necrosis– 30% mild hypersens and
numbness– 60% cold insens– 70% tenderness on
percussion
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Moberg Volar Flap Advancement
Keep NV pedicle thus move dermis with sensation
Problems• FFD – only advance 1cm • Best in thumb ( more skin,
less prone to FFD)• Necrosis• Can reduce blood supply to
flexor tendon ( ?sig)
Preserves length and finger sensitivity
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Thenar Flap vs Cross Finger Pedicle
• Volar skin loss with exposed FDP
• Young pts with no OA index and middle – thenar flap better
• Ring or little -cross finger flap better
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Thenar Flap
• Index & middle only
• Risk of PIP joint contracture
• Best if age < 30
• Do not use in:– Dupuytren’s– RA
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Thenar Flap
• Gatewood 1926• Smith & Albin H-flap
• Good tissue• Good cosmesis
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Cross Finger Pedicle Flap• Palmar Oblique• When others not possible but
need to preserve length• Can get excellent
reinnervation• Preserve paratenon so can
skin graft on to it• Release bridging pedicle at
3/52• Nishikawa
92% Satisfactory
50% cold sensNone had normal sens60% donor cold sens50% stiffness50% poor cosmesis
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Type III
>50% of phalanx lost –primary shortening and closure
Allows immediate mobilisation
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Type III - Amputation• Fashion bone into a tuft-like tip• Dissect nerves and cut short• Don’t suture Flex Ext – get
reduced excursion especially ulna 3 fingers –quadriga effect and reduced ROM and power
Complications• Intrinsic-plus finger as the free
FDP and it’s lumbrical retract, increasing tension in the lumbrical and its contribution to the intrinsic extensor of the IPJ
• Thus active flexion PIP extension
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Outcomes
• Some cold intolerance in 30 – 50% adults with pulp loss
• 30% have altered sensation• This is regardless of the type of
treatment
• Possibly worse outcomes following skin grafting
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Conclusions
• Aims of treatment of fingertip injuries– Provide a useful pain free tip with good
sensation– Provide an acceptable cosmetic result
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Conclusions
• Many techniques have been described for managing finger tip amputations
• Use the simplest appropriate method
• Nail bed injuries need accurate repair and a stable base
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Recent Literature
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References
• Roberts JO, Fenton OM. Management of Fingertip Injuries. Hospital Update 1988
• Kleinert et al. The Deformed Finger Nail, a Frequent Result of Failure to Repair Nail Bed Injuries. J of Trauma 1967;7:177
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References
• Green DP, ed. Operative Hand Surgery. Vol 1&2.London: Churchill Livinstone 2005
• Smith, P. Lister’s the Hand Diagnosis and Indications: Churchill Livinstone 2002