FINGER TIP INJURIES. There complete evaluation and management

FINGER TIP, NAIL BED AND
NAIL PLATE INJURIES

INTRODUCTION
• Fingertip injury is any soft tissue, nail or bony
injury distal to insertion of the long flexor and
extensortendon of afinger orthumb.
• Acutefingertip andthumb injuriesare common
andrequire prompt andmeticulousrepair.

EPIDEMIOLOGY
• Canaffect all agesbut commonin workingclass
adultsandchildren.
• Inadults
– SharpLaceration(Most common)
– Crush& Avulsioninjuries
• Inchildren
–Most injuriesariseat homeanddueto
jamming/crushingbydoors

CLINICAL PRESENTATION
• Physical Examination
– Inspection
• CrushvsSharp injury
• Presenceorabsenceof exposedbone
• Redline sign
• Ribbonsign
• Nailor Nailbedinvolvement
• Viability oftip
• Presenceof foreignbody
– Rangeof motion
• FlexorandExtensortendon involvement

CLINICAL PRESENTATION
• Imaging
–AP& LateralRadiographto assessthebony
involvement.

ALLENS CLASSIFICATION
Type Feature
Type I Involving pulp only
Type II Pulp & Nailbed
Type III Distalphalanx fracture with pulp & nailbed
Type IV Lanula,Distalphalanx fr, Pulp & Nailbed

CLASSIFICATION-PNB
• Evan& Bernadis(2000)
• Toocomplexfor dailyclinicaluse

Perionychium -nail bed, paronychium.
Paronychium -lateral skin surrounding the nail bed and nail.
Hyponychium – keratin plug
Nail wall - skin over the dorsum of the nail fold.
Eponychium- Extension of the nail wall distally onto the
dorsum.
Cuticle or nail vest - eponychium is attached to the nail by a
cornified material.
Lunula - The white, convex opacity extending distally from
beneath the eponychium, which is the distal visible extent
of the germinal matrix.

SUBUNGUAL HEMATOMA
Injury to the nail bed, causing bleeding beneath
the nail.
Separation of the nail from the nail bed.
The pressure of bleeding in this closed space
frequently results in throbbing pain.

TREATMENT
Small and asymptomatic hematomas (<50%) can
be observed.
Repair of the nail bed was advocated with a
hematoma >50% and an associated distal phalanx
fracture.

There is insufficient evidence to justify nail removal
and nail bed exploration in patients who present
with the acutely painful traumatic subungual
haematoma with an intact nail and nail margin,
even in the presence of a distal phalangeal fracture

CONCLUSION
Leaving the nail in place is recommended for most
subungual hematomas with an intact nail.
Exceptions may include children or patients with
concern for an optimally aesthetic nail.
If the nail is broken or the edge disrupted, removal
of the nail and exploration of the nail bed are
advised.
The acutely painful subungual hematoma should
be decompressed, whether done by trephination
or nail removal.

TREATMENT
The nail plate is gently removed from the nail bed
with a small periosteal elevator or iris scissors.
Careful removal of the nail is important to avoid
further injury to the nail bed.
Once removed, the nail is scraped to remove
residual soft tissue, then soaked in povidone-
iodine (Betadine) solution.
The nail bed is examined with loupe magnification.

NAIL BED REPAIR
The nail bed handles like wet tissue paper.
Each suture should be thrown with two bites.
Be conservative with the placement of sutures.
The goal is simple – re-approximation.
Tension on the nail bed suture line will lead to
excessive scarring.

SIMPLE LACERATIONS
Ragged edges – leave let the nail mould them
Undermining of edges upto 1mm done and
reapproximated with 7’0 absorbable suture to
avoid tension during closure.

COMPLEX STELLATE LACERATIONS OR
CRUSH INJURIES
Small fragments should be gently removed with a
periosteal elevator and used as a nail bed graft.
A split- or full-thickness nail bed graft up to 1 cm in
diameter will usually survive, even when it is placed
directly on the distal phalanx cortex.
Blood supply to the graft is established by inosculation
and vascular ingrowth from the periphery.
Split-thickness nail bed graft may be harvested from an
adjacent noninjured finger or an amputated finger.
If larger grafts required – great toe

AVULSION INJURIES
Occurs at the level of the
germinal matrix and
proximal nail fold, leaving
a distally based nail bed
flap of germinal or sterile
matrix
The nail bed remains
attached to the nail

The nail fold is exposed
with unilateral or
bilateral incisions
perpendicular to the
lateral corners of the
eponychium.
The incisions should be
made at a 90° angle to
the eponychium to
prevent a notch
deformity

If the laceration occurs
at the junction of the
ventral and dorsal roof
of the nail fold, suture
approximation may not
be possible.
Horizontal mattress
stitch is placed through
the proximal end of
the avulsed nail bed
and brought out
through the nail wall.

NAIL PLATE REPLACEMENT
Trim the nail plate of sharp contours.
Place the nail plate under the eponychial fold for a
distance of 2–3 mm.
An absorbable suture can be used to hold the nail
plate in place as an alternative to nylon. This will
avoid painful suture removal.

Postoperative care
The fingertip is dressed with nonadherent gauze, 2
-inch roll gauze, and a four-prong splint to protect
the repair.
At 3–7 days after repair, the holding suture is
removed, especially if it is in the proximal nail fold
position.

Fingertip injuries should be thoroughly irrigated and
debrided of foreign material and nonviable tissue before
closure is attempted.
If the entire defect cannot be closed primarily, the
wound can be partially closed and the remainder
allowed to heal by secondary intention.
Wounds up to 2–3 cm may be allowed to heal by re-
epithelialization, but both surgeon and patient must be
aware that closure may take 4–6 weeks.
Secondary intention -improved contour, sensation, and
lack of donor site morbidity.

Wound should be closed with a chromic or other
resorbable suture.
Nylon sutures in the fingertip are not usually
necessary; they are uncomfortable to remove in the
early follow-up periods.
The wound is covered with a non-stick dressing like
Xeroform or other minimal adherence dressing.
Daily dressing changes permits rapid wound healing.
Early motion is encouraged to prevent stiffness at the
DIP or PIP joints.

SKIN GRAFTING
Defect is limited to skin
Split- or full-thickness skin graft
SSG – Contraction ,poor innervation and protective
function.

CAP OR COMPOSITE GRAFT
CAP GRAFT - amputated part may be replaced as a
composite graft after defatting.
Cap grafts are most successful for Zone I and II
sharp or blunt-cut injuries.
Zone III or IV injuries regardless of mechanism
should be treated by another method.
Better results seen in Children.

Complete take (7.7%), Partial take (59%) and (33.3)%
had total loss of the graft.
Despite this seemingly poor overall success of
composite grafts, only 10% of patients went on to
require a secondary procedure.
Indications- patient/family dissatisfaction, persistent
pain, or aesthetic deformity.
Composite graft placed on a fingertip that does not
revascularize should be left as a biologic dressing to
allow healing from below the eschar.
This often leads to an adequately contoured fingertip

LOCAL FLAPS
Volar V–Y advancement (Atasoy, Kleinert)
INDICATIONS - Fingertip defects less than one
centimeter ,dorsal oblique or transverse fashion
Flap is oriented as a triangle and closed in a V–Y
fashion.
The base of the triangle sits at the wound edge
and the apex at the DIP crease.

This skin is incised down through the dermis and then
scissor dissection is used to release fibrous septae that
anchor glabrous skin to the deeper musculoskeletal
structures.
The most distal corners of the flap must be freed by 2–3
mm in order to allow adequate release of the flap distally.
Similarly, the apex of the flap at the DIP joint must be
released significantly to permit distal migration of the flap.
The flap is elevated with its neurovascular pedicles on
either side of the flap in the plane of flexor tendon sheath

0.75–1 cm of length can be obtained with a volar
V–Y advancement flap.
Functional and cosmetic results are extremely
good as this flap remains one of the most
important tools in treatment of fingertip injury
closure

Lateral V–Y advancement flaps (Kutler)
INDICATION- Transverse and lateral oblique defects
The dorsal incision is deepened down to the bone and then
moves anteriorly beneath the flap.(leave millimetre of skin at the
margin of the nailfold)
The volar incision is only carried through skin and takes in
approximately one-third of the skin margin of the defect at the
end of the finger
Once the two flaps are mobile they are sutured to each other and
in the midline to the remains of the nail otherwise the joined
flaps tend to prolapse in a volar direction
Limited mobility and can only reliably close defects of 0.5 cm
Point of convergence of the three scars lies at the point of
maximum use of the pulp and annoying sensitivity here can be a
problem

Visor flap
INDICATION- Transverse distal fingertip
amputations with exposed bone

The visor flap –bipedicled, dorsal aspect of the finger.
Raised at the level of the paratenon.
The width of the flap is approximately that of the
fingertip defect.
The flap is sensate and vascularized by branches of the
volar digital arteries & nerves.
Back cuts in the dorsal aspect of the skin may be
required for transposition of the flap.
The donor site requires a skin graft.
If dog ears are present, they are left in place and
should flatten over a period of months.

Reconstruction of skin and pulp loss at the
fingertip, or skin loss over a flexor tendon.
When planning the flap a digital Allen test should
be used to confirm that both arteries are
adequate.
The flap is raised from the side of the proximal
phalanx (distal two-thirds), but may be extended
proximally to encroach on part of the web skin.
From the planned skin island a zig-zag incision is
made to the distal defect.

Reverse digital artery island flap

With a tourniquet on the arm the volar and proximal margin
of the flap is incised first and the digital artery located and
ligated at the proximal margin.
Release the tourniquet and check the blood supply to the
digit through the contra lateral vessel at this point before
finally dividing the artery.
The remainder of the flap is incised and dissected off the
proper digital nerve either dividing the dorsal nerve branch
and taking it with the flap or leaving the branch on the
finger.
At the distal end of the flap it is important to leave a cuff of
adipose tissue around the digital artery to provide a venous
drainage channel

ReverseDigital Artery IslandFlap

If harvesting the flap with the dorsal branch of
nerve for an innervated fingertip reconstruction
then it is worth dissecting this out proximally so as
to have up to 2 cm projecting from the flap for
microsurgical attachment to the damaged proper
digital nerve.
Do not close the skin edges of the zig-zag incision,
particularly if a neurorrhaphy has been carried out.
Close the donor area with FTG

Volar advancement flaps on the
thumb

MOBERG FLAP
A volar oblique injury to the tip of the thumb is the
classic indication for this flap.
The volar skin of thumb is supplied by digital
arteries.
Dorsal skin is supplied by separate vessels - the
ulnodorsal vessel being a branch of the first dorsal
metacarpal artery and the radiodorsal vessel a
branch of the radial artery.

TECHNIQUE
Mid lateral incision dorsal to neurovascular
bundles.
Flap dissected off flexor tendon sheath
Advanced of the palmar skin
Helped with some IP flexion

DELLON MODIFICATION
Flap elevation can extend proximally onto the
thenar eminence, allowing coverage of wounds 3
cm in size.

Bipedicle island advancement
(O’ BRIEN)

Transverse incision at the level of the proximal
third of the proximal phalanx taken through skin
only.
The neurovascular pedicles are then dissected out
from beneath the proximal flap to permit
mobilisation of me distal skin island.
This island is then advanced and the secondary
defect filled with a full thickness skin graft.

Unipedicled rotation-advancemen t
flap (HUESTON)
With smaller defects (8 mm) it may be possible to
avoid bilateral mid-axial incisions and carry out a
rotation advancement of the volar thumb skin
based only on the vascular pedicle of one side
The base of the flap is classically positioned on the
ulnar side of the thumb so as to preserve
maximum innervation to the ulnar side of the
reconstructed tip.

Thumb radiodorsal neurovascular flap
(Pho)
Dorsal branches of the radial palmar digital artery given off
at the level of the neck of the proximal phalanx of the
thumb.
The dorsal margin of the flap passes dorsally from the
defect some 3 mm away from the nail edge, taking as much
as necessary over the dorsum, and then curves down to the
mid-lateral line at the proximal third of the proximal
phalanx.
The volar margin follows the edge of the pulp defect and
then approaches the mid-lateral line along which an incision
is made to the metacarpal head to expose the pedicle.
Flap transposition after mobilising the pedicle is facilitated
by flexion at the joints, and the secondary defect is grafted

Advancement flaps of the digits

Unipedicled island advancement flap
(Venkatswamy)
lateral or medial oblique tip loss by advancing a
triangular island flap from the less damaged side.
The base of the flap is as wide as the defect and the
other two sides are 2 to 21/2 times long as base.
The dorsal incision is deepened to a plane beneath the
subcutaneous fat so that the neurovascular bundle is
raised with the flap.
On the volar side the incision is through skin, and
fibrous septa are divided with scissors preserving
vessels and nerves entering the volar side of the
triangle.

Unipedicled island advancement flap
(Venkatswamy)

Dorsolateral island advancement flap
(JOSHI)
Neurovascular island flap from the dorsum and
lateral aspect of a finger.
The volar margin of the flap borders the defect and
then tapers towards the mid-lateral line at the PIP
joint crease.
The dorsal margin of the flap passes from the
defect past the proximal corner of the nail, about 3
mm from it, reaches the midline on the dorsum of
the finger and then tapers down to meet the volar
incision at the PIP joint crease.

The dorsal incision is made and attempts made to
retain a dorsolateral vein at this point .
The flap is advanced with the MCP joint flexed and
the donor site reconstructed with a full-thickness
graft.

Dorsolateral island advancement flap
(JOSHI)

Step advancement island flap (Evans)
Advancement – without secondary defect
The volar margin of the flap is designed as three
triangles, narrow proximally and wide distally, with
only the distal flap crossing the midline.
The dorsal incision is slightly convex and tapers
proximally to meet the volar incision at a point
overlying the neurovascular bundle.
Complete apposition of dorsal skin edges is
avoided if this would mean putting the flap under
tension and any gaps heal secondarily.

Step advancement island flap (Evans)

BipedicIed island flap (O'Brien)

BipedicIed island flap (O'Brien)
Mid-lateral incisions reach from the edges of the
defect to the PIP joint.
Transverse incision is made through skin only and
the neurovascular bundles further mobilised from
beneath the proximal skin.
Lateral ' ears' at the end of the flap are joined
together in the mid line, a very adequately
rounded and projecting pulp is obtained.

Oblique dorsal flap (Flint & Harrison)
Good sensation because the palmar digital nerve gives
branches of supply to the skin over the dorsum of the
DIP joint and these branches are included in the flap
together with adjacent branches of the digital artery.
The proximal incision runs from the PIP joint crease at
the mid-lateral line,obliquely across the dorsum of the
finger to the DIP joint crease on the opposite side.
The distal incision is placed parallel with this and
sufficiently far away to provide enough width of skin to
resurface the front of the finger .
A back-cut into the base of the flap after locating the
vessels, allows transposition into the defect

Oblique dorsal flap (Flint & Harrison)

THENAR FLAP
Based on the radial aspect of the palmar thenar crease.
It is most often utilized for the index and long fingers
because of their proximity to the thumb
Defects upto 1.5cm (Primary closure)
Care must be taken not to injure the neurovascular bundles
that lie immediately beneath the fasciocutaneous thenar
crease flap.
The injured finger must be flexed at the PIP and often the
DIP joint in order to allow flap inset.
Sensation is reported to be better than skin grafting to the
affected digit or with cross-finger flaps.
COMPLICATIONS- Permanent stiffness or PIP joint
contractures

Beasley -four guidelines
1. The metacarpal phalangeal joint of the recipient
finger is fully flexed in an attempt to limit
required flexion of the PIP joint
2. The thumb is placed in full palmar abduction or
opposition
3. The flap is designed with a proximal pedicle high
on the thenar eminence so that its lateral margin
is at the metacarpophalangeal skin crease
4. The pedicle is divided after 10 to 14 days

CROSS FINGER
The rectangular flap is raised on the dorsum of a
finger middle phalanx with the base of the flap
along the medial or lateral side and the flap turned
over through180degree.
Division of Cleland's ligaments in the base of the
flap improves its mobility.

VARIATION
Longitudinally oriented flap over dorsum of middle
phalanx with distal base.
The distal based flap has good blood supply enters
it from the superficial arcade over the base of the
distal phalanx but it is advisable to restrict the
length-to breadth ratio to 1.5 to I.

Innervated cross finger flaps - Thumb

REVERSE CROSS FINGER FLAP
This flap consists of subcutaneous tissue elevated from
the dorsum of the middle phalanx of the adjacent
finger.
This is exposed by first elevating the skin of the donor
digit in this region, maintaining a base laterally, on the
side opposite the injured digit.
The flap is turned over to cover the dorsal defect of the
injured finger.
The elevated skin from the donor digit is then sutured
back into its native position and the flap on the injured
digit is skin grafted.

Heterodigital neurovascular island
flaps (Littler)
Neurovascular island flap
utilizes the donor skin from
the ulnar aspect of the long
or ring finger to provide
sensate vascularized tissue
to a given recipient site.

Heterodigital neurovascular island
flaps (Littler)
Arteriograms and digital Allen’s tests have been
advocated prior to performing this flap to confirm an
adequate co-dominant arterial supply to the donor and
adjacent finger.
Before ligating and dividing the contralateral branch, a
temporary clip should be applied, the tourniquet
released, and the viability of the finger verified.
Creating chevron incisions lateral to the DIP and PIP
creases is important to prevent contractures at these
joints following healing of the skin graft.

COMPLICATIONS
Donor site - stiff fingers with contractures
Cortical relearning or plasticity

FDMA (First Dorsal Metacarpal Artery
Flap)
Reconsttuction of ulnar side defects of the volar
thumb pad.
Skin and subcutaneous tissue of the proximal
phalanx of the index finger

FDMA (First Dorsal Metacarpal Artery
Flap)

The first dorsal metacarpal artery supplies vascularity
in the vena comitantes and some superficial veins
supply the venous outflow of the flow.
Branches of the superficial radial nerve provide
sensibility to this flap.
The flap is elevated at the plane above the paratenon
The rest of the pedicle is dissected and the flap can
either be transposed through a tunnel or through a zig-
zag incision into the volar thumb defect.

Distal phalanx fractures
Distal phalanx fractures are found in approximately
50% of nail bed injuries and result in a higher
incidence of secondary nail deformities.
X- RAY IS A MUST ( MINIMUM 2 VIEWS)

Seymour fracture
Seen in children with the appearance of an
elongated nail.
The fracture occurs through the physis with
interposed soft tissue, usually consisting of nail
bed matrix but can include other tissues, like
eponychial fold.

TREATMENT
Reduce the fracture and fix it with k- wire
Repair the nail bed

FINGER TIP INJURIES. There complete evaluation and management

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