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Soft-Tissue Injuries of the Fingertip:  Methods of Evaluation and Treatment  An Algorithmic Approach 5.13.2009 R3  周邦昀
 
Anatomy  <ul><li>Fingertip  </li></ul><ul><ul><li>The portion of the digit distal to the insertion of the flexor and exten...
Fingertip anatomy
Evaluation  <ul><li>Focused history and physical examination </li></ul><ul><ul><li>Patient’s age, sex, occupation, hand do...
Evaluation <ul><li>Details on  </li></ul><ul><ul><li>the size of the defect </li></ul></ul><ul><ul><li>the presence of exp...
Injury geometry
Treatment  <ul><li>Basic tenets of fingertip reconstruction </li></ul><ul><ul><li>Providing durable coverage </li></ul></u...
 
 
Soft-Tissue Loss without Exposed Bone <ul><li>Distal tip defects (1.5 cm2) </li></ul><ul><ul><li>2nd intention healing </l...
Soft-Tissue Loss without Exposed Bone <ul><li>Skin grafting </li></ul><ul><ul><li>Hypothenar eminence </li></ul></ul><ul><...
Soft-Tissue Loss with Exposed Bone <ul><li>Bone Shortening </li></ul><ul><ul><li>When the distal phalanx is debrided, the ...
Soft-Tissue Loss with Exposed Bone <ul><li>Beasley’s  principles </li></ul><ul><ul><ul><li>the amount of exposed distal ph...
Treatment by Wound Geometry <ul><li>Dorsal Oblique Injury </li></ul><ul><ul><li>Relative preservation    volar skin and p...
V-Y advancement flap
Dorsal Oblique Injury <ul><li>Volar V-Y advancement flap  </li></ul><ul><ul><li>Advanced 1 cm </li></ul></ul><ul><ul><li>I...
Dorsal Oblique Injury <ul><li>Perionychial injury </li></ul><ul><ul><li>Ablation  </li></ul></ul><ul><ul><ul><li>less than...
Nail-lengthening procedure
Transverse Injury <ul><li>Dorsal loss is similar to the amount of volar loss </li></ul><ul><li>Kutler   </li></ul><ul><ul>...
Oblique triangular flap
Hueston flap
Lateral Oblique Injury <ul><li>Injured in the sagittal plane with radial or ulnar tissue loss </li></ul><ul><ul><li>Homodi...
Lateral oblique injury geometry
Lateral pulp flap
Volar Oblique Injury <ul><li>Unlike dorsal oblique injuries, volar oblique injuries are more difficult to manage </li></ul...
Thumb  <ul><li>Moberg </li></ul><ul><ul><li>Volar advancement flap </li></ul></ul><ul><ul><li>Excellent first-line option ...
Moberg volar advancement flap
Thumb  <ul><li>Increase the amount of advancement </li></ul><ul><ul><li>A transverse incision across the base of the flap ...
Thumb  <ul><li>Larger volar thumb defect require reconstruction </li></ul><ul><ul><li>Pedicled  Littler  neurovascular isl...
First dorsal metacarpal artery flap
Index finger <ul><li>Homodigital procedures are preferred </li></ul><ul><ul><li>being single-stage reconstructions </li></...
Index finger <ul><li>Thenar flap </li></ul><ul><ul><li>Best option for more coverage,  Gatewood </li></ul></ul><ul><ul><li...
Thenar flap <ul><li>Fair sensibility (7-mm static two-point discrimination) </li></ul><ul><li>Low donor-site morbidity </l...
18 months postoperatively
Middle finger <ul><li>Character  </li></ul><ul><ul><li>Length rather than sensibility is most important </li></ul></ul><ul...
Ring and small fingers <ul><li>The primary function of the ring and small fingers </li></ul><ul><ul><li>Power grip </li></...
Volar oblique traumatic injury
Cross-finger flap from the middle finger
Composite Grafting <ul><li>Simple nonmicrovascular reattachment of the distal fragment </li></ul><ul><ul><li>Good results ...
Revision Amputation <ul><li>Options </li></ul><ul><ul><li>Laborers who desire a rapid return to the workforce </li></ul></...
Replantation <ul><li>Multiple retrospective studies </li></ul><ul><ul><li>Replantation at the level of the nail fold or be...
Conclusion  <ul><li>Fingertip injuries are among the most common injuries that plastic surgeons are asked to treat </li></...
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  1. 1. Soft-Tissue Injuries of the Fingertip: Methods of Evaluation and Treatment An Algorithmic Approach 5.13.2009 R3 周邦昀
  2. 3. Anatomy <ul><li>Fingertip </li></ul><ul><ul><li>The portion of the digit distal to the insertion of the flexor and extensor tendons on the distal phalanx </li></ul></ul><ul><ul><li>Perionychium </li></ul></ul><ul><ul><li>Nail plate and nail bed </li></ul></ul><ul><ul><li>Hyponychium </li></ul></ul><ul><li>Volar pulp </li></ul><ul><ul><li>Half (56 percent) of the fingertip volume </li></ul></ul><ul><ul><li>Plays a fundamental role </li></ul></ul><ul><ul><ul><li>in grip, proprioception, and sensation </li></ul></ul></ul>
  3. 4. Fingertip anatomy
  4. 5. Evaluation <ul><li>Focused history and physical examination </li></ul><ul><ul><li>Patient’s age, sex, occupation, hand dominance, and mechanism of injury </li></ul></ul><ul><li>Comorbid illnesses </li></ul><ul><ul><li>Diabetes, Raynaud’s phenomenon, or tobacco use </li></ul></ul><ul><ul><li>May limit the reconstructive options </li></ul></ul><ul><li>Complete evaluation </li></ul><ul><ul><li>Neurovascular status and both tendon systems </li></ul></ul><ul><ul><li>Digit-specific radiographs </li></ul></ul>
  5. 6. Evaluation <ul><li>Details on </li></ul><ul><ul><li>the size of the defect </li></ul></ul><ul><ul><li>the presence of exposed bone </li></ul></ul><ul><ul><li>the geometry of the injury </li></ul></ul><ul><li>Composition of the amputated tissue </li></ul><ul><ul><li>should be classified into skin, pulp, bone, and nail bed </li></ul></ul>
  6. 7. Injury geometry
  7. 8. Treatment <ul><li>Basic tenets of fingertip reconstruction </li></ul><ul><ul><li>Providing durable coverage </li></ul></ul><ul><ul><li>Preserving sensation and length </li></ul></ul><ul><ul><li>Minimizing discomfort </li></ul></ul><ul><ul><li>Expediting return to work and leisure </li></ul></ul>
  8. 11. Soft-Tissue Loss without Exposed Bone <ul><li>Distal tip defects (1.5 cm2) </li></ul><ul><ul><li>2nd intention healing </li></ul></ul><ul><ul><li>Mennen and Wise , 200 fingertip </li></ul></ul><ul><ul><ul><li>Good results in residual bulk, functional status, and sensation </li></ul></ul></ul><ul><ul><li>Different dressings suggested </li></ul></ul><ul><ul><ul><li>Silver sulfadiazine </li></ul></ul></ul><ul><ul><ul><li>Semi-occlusive dressings </li></ul></ul></ul><ul><ul><li>Disadvantage </li></ul></ul><ul><ul><ul><li>Prolonged time to complete wound healing </li></ul></ul></ul><ul><ul><ul><li>Difficulty returning to work </li></ul></ul></ul><ul><ul><ul><li>Predicated on patient motivation and compliance </li></ul></ul></ul><ul><ul><ul><li>Aesthetic results are worse </li></ul></ul></ul>
  9. 12. Soft-Tissue Loss without Exposed Bone <ul><li>Skin grafting </li></ul><ul><ul><li>Hypothenar eminence </li></ul></ul><ul><ul><ul><li>higher degree of secondary contracture </li></ul></ul></ul><ul><ul><ul><li>be desirable for larger wounds </li></ul></ul></ul><ul><ul><li>Cold intolerance and postoperative tenderness </li></ul></ul><ul><ul><li>Not expedite return to work </li></ul></ul>
  10. 13. Soft-Tissue Loss with Exposed Bone <ul><li>Bone Shortening </li></ul><ul><ul><li>When the distal phalanx is debrided, the support for the nail bed is lost </li></ul></ul><ul><ul><li>Wound contraction occurs, the nail bed can be pulled inferiorly </li></ul></ul><ul><ul><ul><li>Result in a hook-nail deformity </li></ul></ul></ul><ul><ul><ul><li>Prevented by excising the nail bed 2 mm proximal </li></ul></ul></ul><ul><ul><li>Avoid shortening the distal phalanx to a point proximal to the insertion of either the flexor or extensor tendons </li></ul></ul><ul><ul><ul><li>Length </li></ul></ul></ul><ul><ul><ul><li>Distal interphalangeal joint function </li></ul></ul></ul>
  11. 14. Soft-Tissue Loss with Exposed Bone <ul><li>Beasley’s principles </li></ul><ul><ul><ul><li>the amount of exposed distal phalanx is too great </li></ul></ul></ul><ul><ul><li>(1) the importance of good sensibility and tolerance of normal usage </li></ul></ul><ul><ul><li>(2) minimization of donor-site morbidity </li></ul></ul><ul><ul><li>(3) the use of a practical and reliable method with predictable results </li></ul></ul>
  12. 15. Treatment by Wound Geometry <ul><li>Dorsal Oblique Injury </li></ul><ul><ul><li>Relative preservation  volar skin and pulp </li></ul></ul><ul><ul><li>Volar V-Y advancement flap </li></ul></ul><ul><ul><ul><li>Described by Tranquilli-Leali in 1935 </li></ul></ul></ul><ul><ul><ul><li>A full-thickness flap of skin and digital pulp elevated under loupe magnification </li></ul></ul></ul><ul><ul><ul><li>Avoid injury to the neurovascular bundles </li></ul></ul></ul><ul><ul><ul><li>Originally, no extend to DIP </li></ul></ul></ul><ul><ul><ul><ul><li>avoid potential flexion contracture </li></ul></ul></ul></ul>
  13. 16. V-Y advancement flap
  14. 17. Dorsal Oblique Injury <ul><li>Volar V-Y advancement flap </li></ul><ul><ul><li>Advanced 1 cm </li></ul></ul><ul><ul><li>Inset in a tension-free manner </li></ul></ul><ul><li>Atasoy et al. </li></ul><ul><ul><li>reported near-normal motion and sensibility in 56 of 61 patients </li></ul></ul><ul><li>Elliot et al. </li></ul><ul><ul><li>reported the outcome of 101 patients </li></ul></ul><ul><ul><ul><li>long-term sensibility and motion are good </li></ul></ul></ul><ul><ul><ul><li>incidence of pain (14 percent) </li></ul></ul></ul><ul><ul><ul><li>cold intolerance (13 percent) </li></ul></ul></ul>
  15. 18. Dorsal Oblique Injury <ul><li>Perionychial injury </li></ul><ul><ul><li>Ablation </li></ul></ul><ul><ul><ul><li>less than half of the original length remains </li></ul></ul></ul><ul><ul><ul><li>less than 5 mm remains </li></ul></ul></ul><ul><ul><li>In our experience </li></ul></ul><ul><ul><ul><li>proximal to the lunula, the nail should be ablated and revision amputation performed </li></ul></ul></ul><ul><ul><li>Nail-lengthening procedures </li></ul></ul><ul><ul><ul><li>injuries that sacrifice all but the most proximal sterile matrix </li></ul></ul></ul><ul><ul><ul><li>relatively lengthened 2 to 3 mm </li></ul></ul></ul>
  16. 19. Nail-lengthening procedure
  17. 20. Transverse Injury <ul><li>Dorsal loss is similar to the amount of volar loss </li></ul><ul><li>Kutler </li></ul><ul><ul><li>Bilateral lateral advancement flaps in 1947 </li></ul></ul><ul><ul><li>The limitations to this technique </li></ul></ul><ul><ul><ul><li>Limited advancement </li></ul></ul></ul><ul><ul><ul><li>Creation of a volar tip scar </li></ul></ul></ul><ul><li>Unilateral modifications </li></ul><ul><ul><li>have proven more useful </li></ul></ul><ul><ul><ul><li>Oblique triangular flap </li></ul></ul></ul><ul><ul><ul><li>Hueston flap </li></ul></ul></ul><ul><ul><ul><li>Step-advancement island flap </li></ul></ul></ul>
  18. 21. Oblique triangular flap
  19. 22. Hueston flap
  20. 23. Lateral Oblique Injury <ul><li>Injured in the sagittal plane with radial or ulnar tissue loss </li></ul><ul><ul><li>Homodigital flaps </li></ul></ul><ul><ul><li>Lateral pulp flap is particularly useful </li></ul></ul><ul><ul><ul><li>Remaining volar pulp is advanced laterally to cover exposed bone </li></ul></ul></ul><ul><ul><ul><li>The defect then reepithelializes with moist wound care </li></ul></ul></ul><ul><li>> 50% the distal phalanx is amputated </li></ul><ul><ul><li>Revision amputation </li></ul></ul><ul><ul><ul><li>Provide the best functional and aesthetic result </li></ul></ul></ul>
  21. 24. Lateral oblique injury geometry
  22. 25. Lateral pulp flap
  23. 26. Volar Oblique Injury <ul><li>Unlike dorsal oblique injuries, volar oblique injuries are more difficult to manage </li></ul><ul><li>Precious volar skin and pulp are deficient </li></ul><ul><ul><li>Homodigital </li></ul></ul><ul><ul><li>Heterodigital </li></ul></ul><ul><ul><li>Regional flaps </li></ul></ul><ul><li>Best treatment of volar oblique injuries is often digit-specific </li></ul>
  24. 27. Thumb <ul><li>Moberg </li></ul><ul><ul><li>Volar advancement flap </li></ul></ul><ul><ul><li>Excellent first-line option for thumb tip reconstruction </li></ul></ul><ul><ul><ul><li>Radial and ulnar mid-axial incisions are made dorsal to the neurovascular bundles </li></ul></ul></ul><ul><ul><ul><li>Flap elevation proceeds just volar to the flexor tendon sheath, then carried to MP crease </li></ul></ul></ul><ul><ul><ul><li>Flap is advanced distally and sutured to the distal extent of the injury or nail bed </li></ul></ul></ul><ul><ul><ul><li>Limitations </li></ul></ul></ul><ul><ul><ul><ul><li>flap can be advanced only 1 to 1.5 cm </li></ul></ul></ul></ul><ul><ul><ul><ul><li>requires flexion of the IP joint, thus post-op stiffness↑ </li></ul></ul></ul></ul>
  25. 28. Moberg volar advancement flap
  26. 29. Thumb <ul><li>Increase the amount of advancement </li></ul><ul><ul><li>A transverse incision across the base of the flap </li></ul></ul><ul><ul><ul><li>Extra 0.5 cm of advancement </li></ul></ul></ul><ul><ul><ul><li>Defect is repaired with a skin graft or V-Y pattern </li></ul></ul></ul><ul><ul><li>Flap elevation can extend proximally onto the thenar eminence </li></ul></ul><ul><ul><ul><li>Coverage of wounds 3 cm in size </li></ul></ul></ul><ul><li>Volar advancement flaps are rarely recommended in other digits </li></ul><ul><ul><li>Dorsal vascular supply  the princeps pollicis artery </li></ul></ul><ul><ul><li>Others dorsal skin necrosis can occur </li></ul></ul>
  27. 30. Thumb <ul><li>Larger volar thumb defect require reconstruction </li></ul><ul><ul><li>Pedicled Littler neurovascular island flap </li></ul></ul><ul><ul><ul><li>Flap on ulnar surface of the middle finger (or radial surface of the ring finger) with ulnar digital NV bundle pedicle </li></ul></ul></ul><ul><ul><ul><li>Dissected to common digital origin </li></ul></ul></ul><ul><ul><ul><li>Donor recipient nerve </li></ul></ul></ul><ul><ul><ul><ul><li>left in continuity with its donor source </li></ul></ul></ul></ul><ul><ul><ul><ul><li>coapted with the recipient thumb digital nerve, Foucher (thumb sensation 61%) </li></ul></ul></ul></ul><ul><ul><li>The first dorsal metacarpal artery flap </li></ul></ul><ul><ul><ul><li>Dorsum of the index finger proximal phalanx </li></ul></ul></ul><ul><ul><ul><li>Superficial radial nerve </li></ul></ul></ul><ul><ul><ul><li>Sensibility is not quite as good as with the Littler flap </li></ul></ul></ul>Violation of a normal digit
  28. 31. First dorsal metacarpal artery flap
  29. 32. Index finger <ul><li>Homodigital procedures are preferred </li></ul><ul><ul><li>being single-stage reconstructions </li></ul></ul><ul><ul><li>Limited donor-site morbidity </li></ul></ul><ul><ul><li>providing near-normal sensibility </li></ul></ul><ul><li>Volar advancement flaps </li></ul><ul><ul><li>preserve the perforating vessels to the dorsal skin </li></ul></ul><ul><ul><li>spreading dissection method, Macht and Watson </li></ul></ul><ul><ul><li>distal advancement is limited to 1.5 cm </li></ul></ul><ul><li>Greater advancement of up to 2 cm </li></ul><ul><ul><li>homodigital oblique triangular neurovascular island flap </li></ul></ul>
  30. 33. Index finger <ul><li>Thenar flap </li></ul><ul><ul><li>Best option for more coverage, Gatewood </li></ul></ul><ul><ul><li>A full-thickness subcutaneous flap is elevated </li></ul></ul><ul><ul><li>Flap design near the volar and radial surface of the thumb MP joint </li></ul></ul><ul><ul><li>Flap dimensions, 1.5 times as long and wide as the defect </li></ul></ul><ul><ul><li>Divided at 2 to 3 weeks </li></ul></ul><ul><li>Contraindicated in patients </li></ul><ul><ul><li>who are unable to fully flex the PIP joint </li></ul></ul><ul><ul><li>those at high risk for postoperative joint contracture </li></ul></ul>
  31. 34. Thenar flap <ul><li>Fair sensibility (7-mm static two-point discrimination) </li></ul><ul><li>Low donor-site morbidity </li></ul><ul><li>Good aesthetic appearance </li></ul>
  32. 35. 18 months postoperatively
  33. 36. Middle finger <ul><li>Character </li></ul><ul><ul><li>Length rather than sensibility is most important </li></ul></ul><ul><ul><li>Bone shortening should be avoided whenever possible </li></ul></ul><ul><li>Homodigital flaps </li></ul><ul><ul><li>Usually require a small but frequently significant amount of bone shortening </li></ul></ul><ul><li>Thenar flap </li></ul><ul><ul><li>The most appropriate treatment for volar oblique </li></ul></ul>
  34. 37. Ring and small fingers <ul><li>The primary function of the ring and small fingers </li></ul><ul><ul><li>Power grip </li></ul></ul><ul><ul><li>Homodigital flaps may be used, but they often result in a scar across the volar surface </li></ul></ul><ul><li>Heterodigital flaps </li></ul><ul><ul><li>Particularly the cross-finger flap, better choices for the ring finger </li></ul></ul><ul><ul><li>Full-thickness skin flap is raised on dorsal middle phalanx of long finger </li></ul></ul><ul><ul><li>Paratenon covering the extensor preserved for subsequent skin grafting </li></ul></ul><ul><li>Disadvantage </li></ul><ul><ul><li>Sensibility does not routinely permit tactile gnosis </li></ul></ul><ul><ul><li>Preinjury pulp contour is often absent </li></ul></ul><ul><ul><li>Frequent donor-site morbidity </li></ul></ul>
  35. 38. Volar oblique traumatic injury
  36. 39. Cross-finger flap from the middle finger
  37. 40. Composite Grafting <ul><li>Simple nonmicrovascular reattachment of the distal fragment </li></ul><ul><ul><li>Good results only in children </li></ul></ul><ul><li>In adults, documented graft survival </li></ul><ul><ul><li>Approximately 50 percent </li></ul></ul><ul><li>Creation of subcutaneous pockets </li></ul><ul><ul><li>The fingertips deepithelialized </li></ul></ul><ul><ul><li>Reattached without vascular anastomoses </li></ul></ul><ul><ul><li>Buried in a subcutaneous pocket to enhance graft survival by imbibition </li></ul></ul><ul><li>Never be performed </li></ul><ul><ul><li>In smokers or diabetics or in the setting of crush injury </li></ul></ul>
  38. 41. Revision Amputation <ul><li>Options </li></ul><ul><ul><li>Laborers who desire a rapid return to the workforce </li></ul></ul><ul><ul><li>Heavily contaminated human bite wound </li></ul></ul><ul><li>Zachary and Peimer </li></ul><ul><ul><li>The remaining skeleton  a tapered, smooth end </li></ul></ul><ul><ul><li>Digital nerves divided 1 cm proximal to injury, away contact surfaces </li></ul></ul><ul><ul><ul><li>prevent symptomatic neuroma formation </li></ul></ul></ul><ul><ul><li>The digital arteries and dorsal veins  cauterized </li></ul></ul><ul><ul><ul><li>prevent hematomas </li></ul></ul></ul><ul><ul><li>Care must be taken to completely ablate the nail bed </li></ul></ul><ul><ul><ul><li>prevent problematic ungual remnants </li></ul></ul></ul><ul><li>Loss of profundus insertion </li></ul><ul><ul><li>not be advanced distally, as a “quadriga effect” will develop </li></ul></ul><ul><ul><li>profundus tendons share a common muscle belly </li></ul></ul><ul><ul><ul><li>not permit symmetric flexion </li></ul></ul></ul>
  39. 42. Replantation <ul><li>Multiple retrospective studies </li></ul><ul><ul><li>Replantation at the level of the nail fold or between the nail fold and DIP joint </li></ul></ul><ul><ul><ul><li>Survival rate of 70 to 86 percent </li></ul></ul></ul><ul><ul><li>Frequently, these replantations are performed with arterial anastomoses only with nonmicrosurgical techniques for venous outflow, without digital nerve repair </li></ul></ul><ul><ul><ul><li>Leeches or nail removal with anticoagulants </li></ul></ul></ul><ul><ul><ul><li>Static two-point discrimination averages 5.9 to 8 mm </li></ul></ul></ul><ul><ul><ul><li>Most patients regain preinjury function (91 percent) </li></ul></ul></ul>
  40. 43. Conclusion <ul><li>Fingertip injuries are among the most common injuries that plastic surgeons are asked to treat </li></ul><ul><li>Despite these recommendations, the surgeon should proceed with reconstruction only after a thoughtful discussion with the patient </li></ul>
  41. 44. Thanks for your attention !
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