finger tip injury
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FINGER TIP INJURY
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Definition
Injuries to the fingertip area which are distal to the insertion of the flexor & extensor tendons
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IntroductionMost common injuries of the hand
Although maintenance of length preservation of nail important appearance
But, primary goal of treatment:painless fingertip with durable & sensate skin
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Introduction
Methods of treatment:Healing by secondary intentionSkin graftingShortening of the bone & primary closureLocal & regional flapComposite reattachmentMicrosurgical replantation (very rare)
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Anatomy of Fingertip
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Anatomy of Fingertip
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Mechanism of InjuryMechanism of injury:crushingclean amputation
Also: mixed mechanism of injury.
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ClassificationClassification of Allen for Amputations of the Fingertip
(Allen MJ. Conservative management of finger tip injuries in adults. The Hand. 1980; 12: 257-265)
TypeAnatomic Site for Amputation Idistal to fingernail tipIIdistal to tip of distal phalanx (involves distalmost nail bed)IIIdistal to mid-distal phalanxIVdistal to distal PIP joint (entire distal phalanx)
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Classification(Rosenthal EA. 1983. Treatment of fingertip and nail bed injuries.Orthop Clin North Am 14: 67597)
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Classification(Van Beek AL, Kassan MA, Adson MH, Dale V. 1990. Management of acute fingernail injuries. Hand Clin 6:2335; discussion 3738)
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General Principles of Evaluation & Treatment
History taking:Mechanism of injuryAge GenderHandednessOccupationAvocationHistory of previous hand problem & systemic disease
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General Principles of Evaluation & TreatmentWhich finger??
Complete hand examinationSkinVascularityNeurologic functionFlexor & extensor tendon function
Characteristics of the wound
X-rays
AB & tetanus prophylactic
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General Principles of Evaluation & Treatment
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General Principles of Evaluation & Treatment
If more than one treatment option discuss w/ px
Simplest method should be selected
Many managed in ER
Bloodless field
Meticulously debrided & irrigated
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General Principles of Evaluation & TreatmentAny loss of skin / pulp, amount of it
Exposed bone / fracture
Injury to nail bed / perionichial tissue
Level & angle of injury
No loss simple closure (loosely)
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Important Basic PrinciplesPrepare the extremity to the proximal forearm and any potential graft donor sites.Undertake meticulous wound toilet, surgical washout and appropriate yet minimal debridement.Ensure accurate apposition and repair of the lacerated nail bed.Replace like with like tissue if considering a graft.Preserve skin folds surrounding nail margins. Prevent adhesions within nail folds (especially between the eponychial fold and underlying nail bed).Fractures should be accurately reduced. Ensure a flat surface that is long enough for nail growth.Restore finger skin and pulp if feasible.Excise all remnants of the germinal matrix if terminalization is considered.(Klienert et al., 1967)
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Soft Tissue Loss Without Exposed Bone
Appropriate treatment: Skin graftHealing by secondary intention
Still controversy
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Soft Tissue Loss Without Exposed BoneSmaller wounds ( 1cm2) open method, because of its simplicity
Complete healing: 3-5 weeks by wound contraction & epithelialization
7-10 days after injury begin soaking w/ warm water + peroxide solution
Desensitization initiated
Suitable for children
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Soft Tissue Loss Without Exposed BoneLarger wounds if conservative: not durable, so consider skin graft
Should be full-thickness:Contract lessMore durableLess tenderBetter sensibility
Taken from ulnar border of the hand (glabrous skin)Width: up to 2 cmAfter 7 days start ROM exerciseShould not be used indiscriminately
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Soft Tissue Loss With Exposed BoneSatisfactory coverage must be obtained
Composite tip graft only for < 6 y.o
Open method; nail plate deformities
Coverage by Shortening the bone w/ primary closure (revision amputation)Local flapRegional flap
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Soft Tissue Loss With Exposed BoneBased on:Level & angle of amputationAge sex
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Revision AmputationIndication:When not enough sterile matrix remain (< 5 mm)Advanced ageSystemic condition
Remaining nail matrix ablated
If flexor & extensor tendons insertion cant be preserved disarticulation
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Revision AmputationTendons transected & allowed to retract
Prevent painful neuroma
Prominent volar condyle of middle phalang, collateral ligament & volar plate trimmed
Oblique angle (sagittal) use to cover bone
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Local FlapsAdvantages:Can be used for any agePreserve lengthDo not requires skin graftSimilar quality, texture & colourEarly ROM
Requires judgement & expertise
Most commonly used:V-Y / Triangular Volar / Atasoy FlapKutler / Bilateral V-Y Flap
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V-Y / Triangular Volar / Atasoy Flap
Transverse / dorsal oblique amputations
Can be used for all digits
Only 1 cm advancement
Not for too proximal amputation
Trim the bone
Not to damage neurovascular bundle
All fibrous septa must be divided
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V-Y / Triangular Volar / Atasoy Flap
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Kutler / Bilateral V-Y FlapMost appropriate for distal transverse amputation
Dual triangular flap from the lateral side
Without undermining
Disadvantages: small & difficult to advanceFlap necrosisNail deformityHipersensitivity
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Regional FlapsMost commonly used:Cross-finger flapThenar flap
Preserve length
Volar oblique angle
Too proximal amputation
More than 1 finger combination
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Regional FlapsDisadvantages:2-stage procedureProlonged immobilization joint stiffness (not for age > 40)Cross-finger flap donor-site scar: not suitable for female & dark-skinned persons
Contraindicated in:OA of the hands or arthritisSystemic condition: RA, DM, vasospastic disorders
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Regional Flaps
Post-op:Bulky dressingSplintUninjured finger left freeFlap division 12-14 days afterSuturing recipient cut edge: not recommendedAggressive ROM program
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Cross-finger FlapHinge side: adjacent to injured finger
Through subcutaneous tissue
Preserve paratenon
FTSG from groin to cover donor-site
Can be proximally, distally or laterally based
Satisfactory 2-point discrimination (8-10 mm), some had impaired tactile gnosia
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Cross-finger Flap
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Thenar FlapCan be used for any finger, but small finger difficult
Disadvantages:PIP stiffnessTenderness over donor-site
Location: high on thenar eminence
Radial border parallel & adjacent to MCP crest
Proximally based
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Thenar FlapAs wide as 2 cm; 1,5x wider than defect
Not to damage radial digital nerve of the thumb
Donor defect: FTSG
Position: MCP & DIP flexed as much as possible
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Injury of The ThumbSimilar to other digits
Importance of length preservation & restoration of sensibility magnified
Choices:Moberg FlapCross-finger FlapKite FlapLittler Flap
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Moberg Advancement Flap
Indication:Can not be flapped w/ V-Y flap> 2 cm defect
Preserve length & tactile gnosia
Containing neurovascular bundle
Transverse incision
Disadvantages: Flexion deformity
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Moberg Advancement Flap
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Cross-finger Flap
Donor from index finger (prox phalang) or other finger
For loss of > 2/3 pulp tissue
Innervation can be augmented by neurorraphy
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First Dorsal Metacarpal Artery-Island Pedicle Flap (Kite Flap)
1 stageInclude neurovascular bundleBased on 1st dorsal MC ArteryDonor: FTSG
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