1. By Mustafa Z. Hasan

2.  injury to the fingertip can result in significant functional and aesthetic deficit.  The fingertip is the most commonly injured part of the hand, comprising 45% of hand injuries presenting to emergency rooms.  Males are injured more frequently than females, especially in the workplace.  The long finger is most often affected, the thumb and 5th are the least commonly involved.

4.  The main principle of nailbed repair is reapproximating the injured tissue to anatomic position.  The hallmark of injuries to the nailbed is the subungual hematoma. 1- A hematoma involving less than 25% of the visible surface of the nail;  Managed with drainage of the hematoma as necessary for pain relief.

5. 2- A subungual hematoma that occupies more than 25% of the visible surface of the nail;  Failure of primary healing may result in scarring of the matrix, with subsequent deficiency in nail growth or adherence.  The nail is carefully separated from the underlying bed and eponychium  and is set aside in sterile saline for later use.  Debridement of the wound edges should be kept to an absolute minimum.

6.  Lacerations of the nailbed are repaired under loup magnification using precise interrupted suture technique. Fine (6-0 or 7- 0) absorbable suture material on small atraumatic cutting needles is recommended.  if the space between the germinal matrix and the eponychium is not maintained, adhesion may occur, with subsequent distortion of nail growth. The nail itself is the most ideal dressing.

8. 3- Treatment of avulsion injuries to the nailbed;  Segments of avulsed matrix are best replaced as a graft.  If the avulsed tissue is lost or too damaged, the defect can be managed with split- thickness grafts taken from an adjacent uninjured portion of the nailbed.  When larger segments of graft are needed, a toe may be used as a donor site.

10.  very effective for loss of skin up to 1 cm 2, particularly effective in tip amputations in small children.  Contraction of the wound usually results in a small scar that typically is not overly sensitive.  Larger wounds, result in a painful and hypersensitive scar.  If a small portion of distal phalanx is visible, judicious shortening of the tip is allowable. However, if more than half of the phalanx is resected, the patient will develop a "hook nail" deformity from loss of nailbed support.

11.  allows quick coverage of wounds.  in minor fingertip amputations, not involving bone or nailbed.  skin of the amputated part may be replaced.  other donor sites (including the ulnar border of the hand, the volar wrist crease, the antecubital area, or other distant sites)  Disadvantages; instability of the grafted skin, poor tactile return, and hypersensitivity of the fingertip; and because of that patient neglects to use the finger.

12.  ideally suited for transverse or slightly volar amputations at the midnail level.  Disadvantages ; include the limited mobility of these flaps, and placement of a scar directly on the fingertip.

14.  for transverse midnail or dorsally directed fingertip amputations.  Occasionally postoperative hypesthesia, hypersensitivity, or cold intolerance will occur. Additionally, if a tight closure is used over a shortened phalanx this repair is particularly prone to induce a hook-nail deformity.

16.  Although this procedure has been described for all digits of the hand, the Moberg flap is best suited for transverse thumb tip amputations.  Use of a volar neurovascular advancement flap for digits other than the thumb, may lead to dorsal skin necrosis.  Disadvantages ; joint contractures, tip necrosis and painful scarring, seem to occur more frequently when the Moberg or similar flaps are used on digits other than the thumb.

18.  best choice for volar oblique tip amputations. It can also be used for dorsally oriented amputations in either a rotation design or unfurled with deepithelialization of the flap.  Complications include donor-site depression, skin graft hyperpigmentation, digital stiffness, and cold intolerance.

20.  can be used for amputations of any orientation on the index, long, or ring fingers.  Age is not a contraindication to the use of thenar flaps. Thenar flaps have been used with equal success with patients from 1 to 76 years of age.

21. (a)the MCP joint of the recipient finger is fully flexed in a protective position, minimizing PIP joint flexion. Flexing of DIPjoint when present, further improves the position of immobilization. (b) the thumb is placed in full palmar abduction or opposition. (c) the thenar flap is designed with a proximally based pedicle, high on the thenar eminence so its lateral margin is at the MCP skin crease. (d) the pedicle of the flap is severed after 10 to 14 days.

23.  Important hemipulp areas where one might wish to restore sensation are the thumb, index, and the ulnar aspect of the 5th finger  donor site is the ulnar ring finger, or long finger.  sensory loss is experienced in the donor finger  The neurovascular island flap is almost always useful for restoring at least protective sensation to an otherwise anesthetic digital surface.

24.  Surely technical precision in elevating the flap plays some role, but other factors such as lack of cortical reeducation or wound healing problems may decrease the quality of the result.

26.  microsurgery has allowed other options in the treatment of fingertip amputations, but with technical difficulty of very distal replantation.  However, some authors have shown that an acceptable survival rate.  Delayed free-tissue transfer from the toes also yields functional results, while restoring physical appearance to nearly normal.

27.  When flap coverage is needed but options within the hand have been exhausted, the groin flap or the radial forearm flap become the workhorse choices.  fascia-only radial forearm flap with a skin graft to provide a less bulky and more serviceable fingertip in a one-stage procedure.