FINGERTIP INJURIES

ARE THEY REALLY THAT SIMPLE?

SANJAY K SHARMA, MD, FACS

INSTITUTE OF RECONSTRUCTIVE PLASTIC

SURGERY

Austin Trauma and Critical Care Conference 2018

May 31-June 1, 2018

Outline

1. Scope of problem1. Stats

2. Anatomy

3. Case vignettes1. Crush

2. Nail lac

3. Burns

4. Mallet

5. Jersey finger

▪ Solutions DO nothing

Skin graft

Local flaps

Distant flaps

▪ Not going to discuss Nail infections

Abnormal nails

Infections of fingertips

Our hands/fingers

Scope of the problem

Scope of the problem

More like this

National Hospital Ambulatory Medical Care

Survey:

2015 Emergency Department Summary

Tables

Incidence of Hand Trauma

▪ 2015 National Center for Health Statistics

137 million visits

39 million Injury related

Upper Extremity 16% = 6.25 million

Wrist/Hand/Finger 9.1% = 3.55 million

2011:

Upper Extremity 18.3% = 7.39 million

Wrist/Hand/Finger 11.3% = 4.53 million

Goals of treatment

▪ Restore

Closed wound

Protective sensation, painless

Functional digit

▪ Complications to avoid

Nail deformities

Painful neuromas

Insensate or unstable soft tissue

Anatomy

▪ Germinal matrix

▪ Sterile matrix

▪ Eponychium

▪ Paronychium

▪ Lunula

▪ Pulp

Anatomy

▪ Function of nail

Counterforce for pinch

Contributes to tactile sensation

Picking

Nailbed injury

▪ Common mechanisms

Door

Tools

Crush working

Crush working out

Drill accident

Saw

Nail gun

Injury workup

▪ Detailed History Mechanism of injury

▪ Detailed exam Noting level of finger injury

Nail involvement

▪ X-rays

▪ Comfort Local digital block: Marcaine

YES--OK TO USE EPINEPHRINE

Nailbed Trephination

▪ Subungual hematoma

▪ 50% rule

▪ Release the pressure and allow nail to drain

▪ Can use cautery, needle

▪ Over time nail growth occurs at Glacial pace (3-6 months)

Burns

Chemical: Hydro Fluoric Acid Scalding

Electrical Burn

Repair

▪ If basic form is present, can

do suture repair of laceration

▪ In children use absorbable

sutures

▪ Nail bed injuries

Suture repair

Tissue Glue for nailbed

No difference in outcome

Stent the fold

Place the nail plate back under

Helps stabilize the sterile matrix

Stabilize underlying fracture

Will lift off over time

Open Fracture?

▪ Technically yes, open

▪ Rates 0.3-11%

▪ Infection Not Likely for common

mechanisms of injury

Crush, laceration, mechanical

tools

Clean, irrigated, stabilized <24 h

Antibiotics? Tendency to No, but if

going to treat should be less than

72 hours

▪ Beware of these injuries

Animal bites

Human bites

Seymour Fractures

Contaminated, comminuted and

multi-fragmented soft tissue

injury

Delay in presentation

Prophylactic antibiotics in open distal phalanx fractures: systematic review and meta-

analysis.

Metcalfe D, Aquilina AL, Hedley HM.

J Hand Surg Eur Vol. 2016 May;41(4):423-30

The High Risk of Infection With Delayed Treatment of Open Seymour

Fractures: Salter-Harris I/II or Juxta-epiphyseal Fractures of the Distal

Phalanx With Associated Nailbed Laceration.

Reyes BA, Ho CA.

J Pediatr Orthop. 2017 Jun;37(4):247-253

Repair

Need for more coverage—local Flaps

V-Y Flap

Reconstruction/Flaps

Sanjay K. Sharma, M.D., F.A.C.S.

Cross finger flap

Distant Reconstruction

Then there’s this…Fingertip injuries after all

Make due with what you’re given

Secondary Intention

▪ Changing paradigm of

treatment

▪ Can allow slow closure over

bone, tendon

▪ Moist environment

▪ Works great in children

Motivated patients

▪ 3-8 weeks

Secondary Intention

Time Lapse video

Pediatric Fingertips

Most common hand injury in child

Amputations vs soft tissue crush injuries

Supportive care: dressing changes and

splints if distal phalynx fracture

Ultimately good result

Trauma--Fingertips

▪ Seymour Fracture

Displaced physeal or juxtaphyseal distal phalanx fracture

Proximal nail avulsion with nailbed laceration

Open fracture

Unusual variation of fingertip injuries

▪ Mallet Finger

Axial injury

hyperflexion

▪ Boutonniere Deformity

Dislocations

Lacerations

Axial injury

Jersey Finger

▪ Technically Fingertip injury

Hyperextension injury

Avulsion of FDP tendon

Bruising at volar distal phalanx

Inability to bend (flex) DIP

FDP Tendon

Summary

▪ Fingertip Injuries major

healthcare burden

Patient

ED Provider

Workplace/Employer

Physician

▪ Take away points:

Repair accurately

Restore sensate tip with flaps

Realize most if not all Fingertip

injuries will heal spontaneously

Consult your hand surgeon as

needed for guidance

Thank You