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Fingertip injury
- 1. DONE BY: DR. SAADALGHUNAYMI ORTHOPEDICS RESIDENT KING SALMAN MILITARY HOSPITAL TABUK FINGERTIP INJURIES
- 2. OBJECTIVES • INTRODUCTION • ANATOMYOF FINGER TIPS • EVALUATION OF INJURY • MANAGEMNT
- 3. FINGERTIP INJURIES • AFingertip 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 iscomposed 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.
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- 7. cont. The nail bedconsists 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 shouldinclude 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-SUBUNGUALHEMATOMA :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 ◦ nailremoval, 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 causedby 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
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- 18. EVALUATION HISTORY AND P/E NEUROVASCULARASSESMENT X-RAY ANTI-TETANOUS AND ANTIBIOTICS
- 19. TREATMENTNonoperative: ◦ healing bysecondary 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 (revisionamputation) ▪ 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 advancementflap ◦ indications ▪ straight or dorsal oblique finger tip lacerations
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- 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 fingerflap indications: ▪ dorsal finger & MCP lacerations
- 28. VOLAR THUMB INJURY Mobergadvancement volar flap ◦ indications ▪ volar thumb if < 2 cm
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- 30. CONT. Neurovascular island flap ◦indications ▪ volar thumb up to 4 cm
- 31. DORSAL THUMB INJURY Firstdorsal 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 INJURYIS 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 • AmericanSociety for Surgery of the Hand update • Fingertip Injuries springer •Acute fingertip injuries J Chakravarthy, A Qureshi, MA Waldram and K Porter
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