fingertip injuries and management

1. DONE BY:
DR. SAAD ALGHUNAYMI
ORTHOPEDICS RESIDENT
KING SALMAN MILITARY HOSPITAL
TABUK
FINGERTIP INJURIES

2. OBJECTIVES
• INTRODUCTION
• ANATOMY OF FINGER TIPS
• EVALUATION OF INJURY
• MANAGEMNT

3. FINGERTIP INJURIES
• A Fingertip injury is any soft tissue, nail or bony injury distal to the
insertions of the long flexor and extensor tendons of a finger or thumb.
• It is a common injury ,many are simple to treat but in special cases
need to be evaluated by hand orthopedics or plastic surgeons that we
will discuss later on.
• during management surgeon is warranted for better functional and aesthetic
outcomes.
• Common injuries include crush injuries to the fingertip (with resultant subungual
haematoma, nail bed laceration, partial or complete amputation of the fingertips,
pulp amputations and fractures of the distal phalanges

4. ANATOMY
The fingertip is composed of skeletal elements (distal
phalanx, tendons, and ligamentous struc- tures), the nail
complex or perionychium (germi- nal and sterile
matrices, nail plate, sheaths, and skin folds), fibrous
connective tissue network with the subcutaneous tissues,
vascular network, nerves with end organs, and the
nonperionychial skin.

5. ANATOMY
• SKELETAL ANATOMY:
- Attachment of extensor(mallet) and flexors.
The LILs support the nail bed and
help protect the neurovascular structures in the fingertip
-UNGUAL PROCESS (tuft): enlarged termination of distal phalanx
supports the nail bed, nail plate and underlying nail matrix.

6. The Perionychium
(nail complex)

7. cont.
The nail bed consists of two distinct components: the proximal
germinal matrix and the distal sterile matrix. The germinal
matrix is primarily responsible for nail production, contributing
90% of the nail mass.The sterile matrix is primarily responsible
for nail adhesion.
The transition between the skin of the finger and the dorsal roof
the nail fold forms the eponychium.

8. The Nail Plate :
* made of three layers:
-The most dorsal or superficial layer is
thin and provides its sheen and polished
appearance.
-The middle layer is thick
and the ventral or deep layer is
irregular with longitudinal striations.
The majority of the nail is manufactured
by the germinal matrix

10. EVALUATION
-Initial evaluation should include assessment of the mechanism of
injury, hand dominance, vocation, avocation, comorbidities, and
patient goals as well as expectations
- history and physical examination including 2 point
discrimination before digital nerve block .
x-ray for possible bone fracture

11. NAIL BED INNURY
1-SUBUNGUAL HEMATOMA :Most commonly caused by a crushing-type
injury LEADING TO BLEEDING ANDER THE NAIL.
Haematomas involving
up to 25% of the visible
nail bed area should be trephined
Treatment
◦ drainage of hematoma by perforation
▪ indications
▪ less than 50% of nail involved
▪ techniques
▪ puncture nail using sterile needle
▪ electrocautery to perforate nail
◦ nail removal, D&I, nail bed repair
▪ indications
▪ > 50 % nail involved
▪ technique
▪ nail bed repair

12. CONT.
Nail Bed Lacerations
• Laceration of the nail and underlying nail bed
◦ usually present with the nail intact and a subungual hematoma greater than
50% of nail surface area
• Treatment
◦ nail removal with DEBRIDEMENT &IRRIGATTION
nail bed repair WITH
7-0 CHROMIC SUTURES*
▪ indications
▪ most cases
▪ modalities
▪ tetanus and antibiotic prophylaxis
*If the native nail plate is intact, it can be replaced and held either proximally
with a horizontal mattress suture through the nail fold or distally with an
interrupted suture through the hyponychium
IF NAIL PLATE SEVERLY DAMAGE WE CAN USE SILICON

13. CONT.
Avulsion InjuriesTreatment
◦ nail removal, nail bed repair, +/- fx fixation
▪ indications
▪ avulsion injury with minimal or no loss of nail matrix, with or
without fracture
▪ technique
▪ always give tetanus and antibiotics
▪ fracture fixation depends on fracture type
◦ nail removal, nail bed repair, split thickness graft vs. nail matrix
transfer, +/- fx fixation

14. COMPLICATIONS
• HOOK NAIL
caused by advancement of the matrix to
obtain coverage without adequate bony support
▪ Treatment
▪ remove nail and trim matrix to level of bone
• NAIL SPLIT
excise scar tissue and replace nail matrix
▪ graft may be needed

15. Distal Phalanx Fracture
• ASSOCIATED WITH NAIL BED INJURY
• FIXED WITH PERCUTANEOUS K WIRE ,
TRY NOT TO GO DIP
• IN CASE OF COMMINUTED FRACTURE WE REPAIR NAIL BED COZ IT
ACTS AS SPLINT.
• REMOVE K- WIRE AT 3-4 WEEKS TO PREVENT JOINT STIFFNESS

16. SOFT TISSUE
INJURY
FINGERTIP AMPUTATION
• Injury to the finger with variable involvement of
soft tissue, bone, and tendon
• Goals of treatment
◦ sensate tip
◦ durable tip
◦ bone support for nail growth

17. Classification

18. EVALUATION
HISTORY AND P/E
NEUROVASCULAR ASSESMENT
X-RAY
ANTI-TETANOUS AND ANTIBIOTICS

19. TREATMENTNonoperative:
◦ healing by secondary intention
▪ indications
▪ adults and children with no bone or tendon exposed with < 2cm
of skin loss
▪ children with exposed bone
but in kids with no exposed bone or minimal exposed
bone and a small defect, local wound care is the
answer. In less than 2 years of age, composite grafting
is recommended if the amputated part is in good
shape. TO ACHIEVE LENGHT AND FUNCTION.

20. CONT.
Secondary intention:
◦ technique
▪ initial treatment with irrigation and soft
dressing.
▪ after 7-10 days, soaks in water-peroxide
solution daily followed by application of soft
dressing and fingertip protector
▪ complete healing takes 3-5 weeks

21. Operative
primary closure (revision amputation)
▪ indications
▪ finger amputation with exposed bone and the ability to rongeur bone
proximally without compromising bony support to nail bed
full thickness skin grafting from hypothenar region
▪ indications
▪ fingertip amputation with no exposed bone and > 2cm of tissue
loss
flap reconstruction
▪ indications
▪ exposed bone or tendon where rongeuring bone proximally is
not an option.

22. FLAP RECONSTRUTION
V-Y advancement flap
◦ indications
▪ straight or dorsal oblique finger tip lacerations

23. CONT.

24. Digital island artery:
◦ indications
▪ straight or dorsal oblique finger tip lacerations
▪ volar oblique finger tip lacerations
◦ advantages:
▪ best axial pattern flap

25. Cross finger flap :
◦ indications
▪ volar oblique finger tip lacerations in patients > 30 years
◦ advantages
▪ leads to less stiffness

26. Thenar flap :
◦ indications
▪ volar oblique finger tip lacerations to index or middle finger in patients
< 30 years
◦ advantages
▪ improved cosmesis

27. Reverse cross finger flap
indications:
▪ dorsal finger & MCP lacerations

28. VOLAR THUMB INJURY
Moberg advancement volar flap
◦ indications
▪ volar thumb if < 2 cm

29. Moberg advancement volar flap

30. CONT.
Neurovascular island flap
◦ indications
▪ volar thumb up to 4 cm

31. DORSAL THUMB INJURY
First dorsal metacarpal artery flap
◦ indications:
▪ dorsal thumb lacerations
▪ volar thumb lacerations if > 2 cm

32. Complications
• Flap failure
◦ cause
▪ inadequate arterial flow
▪ vasospasm often leads to thombosis at anastamosis
▪ inadequate venous outflow
• Hook nail deformity
◦ cause
▪ tight tip closure
▪ insufficient bony support
◦ treatment
▪ variety of reconstructive procedures have been described

33. SUMMARY
• FINGERTIP INJURY IS COMMON
• CLASSIFICATION FOR PLANING HOW TO MANAGE
• EARLY ASSESSMENT AND EXAMINATION TO PREDICT THE FUTURE OUTCOME
IS IMPORTANT
• OBTAIN CONSENT BEFORE ANY PROCEDURE DONE TO PATIENT IN THE E.R
AND DISCUSS THE BENEFITS AND COMPLICATION OF SUCH INJURIES
• MANAGEMENT IS DEPENDENT ON THE DEGREE OF INJURY
• AIM OF MANAGEMENT IS TO RESTORE THE FUNCTION AND COSMETIC
FEATURES
• START WITH ANTI-BIOTIC +ANTI-TETANOUS PROTOCOL AND THE NEED FOR
IRRIGATION AND DEBRIDEMENT

34. REFRENCES
• orthobullets
• American Society for Surgery of the Hand
update
• Fingertip Injuries springer
•Acute fingertip injuries
J Chakravarthy, A Qureshi, MA Waldram and
K Porter

35. thank you