1. Fingertip Injuries Anthony Perera Andy Mahon

2. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity (2pt discrimiantion reduce without it to acts a counterforce) Paronychium Hyponychium – Sterile Matrix-adheres to the nail by adding squamous epithelial cells to the advancing nail, making it thicker, stronger and more adherent. Attached to periosteum Germinal Matrix –gradient perkeratosis -3mm/month

3. Surgical Anatomy Germinal matrix –distal extent of lunula, ave. distance to end of Extensor is 1.2mm thus care, but if you see the extensor then you have cleared the whole of it. Dorsal nail fold – 10% of nail growth (and shine) thus can get spicules, need to prevent it sticking down. Sterile matrix- if not accurately reduced get abnormal nail.

4. Fingertip Injuries Subungual haematoma Nail bed laceration Distal phalanx fracture DIPJ dislocation Mallet finger FDP rupture

5. Subungual Haematomas If >25 % of nail then risk of nail bed injury If >50% high risk of significant injury Thus >25% -trephine >50% and high energy –remove nail and inspect nail bed

6. Nail Bed Injury Classification I-Small haematoma (>25%) II-Large haematoma (>50%) III-Laceration + Fracture IV-Nail bed Fragmentation V-Nail bed Avulsion +/-paronychium +/-whether it involves S or G matrix

7. Nail Bed Injury Management REQUIRES NAIL REMOVAL If -haematoma >25% (Zook and Brown) -# -dorsal nail fold or paronychyia disrupted -Avulsed nail Not in children (Roser J Hand Surg 99 –RCT)

8. Principles of Operative Management 1.Remove nail 2.Reduce and fix # 1 st (K wire or figure of 8 suture) 3.Open corners of dorsal nail fold to improve view 4.Replace all of nail bed and accurately repair 5.When all nail bed not available consider grafting 6.Clean nail and replace ( or use foil packet) 7.Either trephine or use glue 8.Repair dorsal fold (or appropriate graft)

9. How to Deal With Tissue Loss Sterile Matrix -ST graft,v thin so no donor site deformity -take 1-2mm more than needed – it contracts -Place in same axis -If periosteum stripped–decorticate bone Germinal Matrix -can do rotation flaps if small -if >1/3 can take from toes ( S or FT) - not as good–both sites get deformity Dorsal Nail Fold -rotation flap - ? Put ST sterile matrix graft on undersurface

10. Post –Op Management Dressing 7-10 dys –protect nail Start desensitsation at 2/52 Move immediatel unless # K wire out at 4/52 New nail pushes old one out at 2-3 weeks Complications Non-adherence or ridging of plate Split nail Crooked nail plate Hooked nail

11. Dealing With Complications 1.Non-adherence/ ridging Due to granulation tissue from poor repair of nail bed Rx –scar excision 2.Split Nail Due to longitudinal scar in matrix Rx –excise and graft Due to adhesions Rx –graft and stent apart 3.Crooked Nail Plate Due to sterile matrix contracture on 1 side Rx –excise and full thickness graft

12. Dealing With Complications 4.Hooked Nail Due to insufficient bony support Rx – AVOID, don’t use nail bed to cover partial amputation Distal edge of sterile matrix should be at least 2mm from distal edge of bone can shorten nail bed or release it distally to allow retraction proximally If uncorrectable nail deformity - can fully excise and use full thickness skin graft

13. Fingertip Injuries Goals of Treatment 1.Preserve Function 2.Durable coverage 3.Preserve useful sensibility 4.Prevent symptomatic neuromas 5.Prevent joint contracture 6.Shorten recovery 7.Reduce morbidity 8.Preserve length –especially thumb

14. Fingertip Injury Classification

15. Management Type IPrimary Closure Secondary healing Composite grafts Split thickness skin graft Type IIShorten and close Coverage Type IIIAmputation

16. Type I -1 O Closure + 2 O Healing Equivalent Results Primary – if no tension Secondary – if <1cm and no exposed bone, volar cuts ?pulls in innervated tissue

17. Conservative Management Patients / parents may need convincing Some doctors too! Before and after pictures of example cases Particularly in children Das, Brown 1978

18. Type I -Composite Grafts Children – at mid-level or distal to nail bed. Need to explain will scab off. Rose – near normal appearance, 2 pt 6.5mm, no infections

19. Type I- 2 O Healing vs Grafting Holm and Zachariae- 5 year FU 2 O STSG Good90%50% Cold Sens39%33% Dec Sens26%67% Pain at Site71% Return to workInc ComplicationsInc Mennem and Wiese Even if bone exposed near normal shape, useful epithelium, no complications, no hook nail, excellent sens

20. Type II 1.Shorten and conservative 2.Shorten and close, see at 2-3 days ? Antibiotics Manual labourers- return to work 6-8 weeks If not enough bone then trim nail bed back to avoid hook nail. 3.If important to preserve length – need coverage

21. Type II- Coverage 1.Atasoy-Kleinert Volar V-Yplasty 2.Kutler Lateral V-Y flaps 3.Moberg Volar flap Advancement 4.Cross-finger Pedicle flap 5.Neurovascular Island Flaps

22. Advancement Flaps Nice technical exercises! Preserve length Originators results seem better than others

23. Atasoy-Kleinert V-Yplasty Nail bed and pulp with exposed bone (CI –if loss palmar >dorsal) Apex of triangle at DIP Problems ( Atasoy 56/61 normal sens + ROM) 70%hypo-dyaesthesia 40%cold sens 50% difficulty with grasping

24. Kutler Lateral V-Y plasty Transverse amputation Useful in dorsal oblique Problems –If too large can get necrosis –30% mild hypersens and numbness –60% cold insens –70% tenderness on percussion

25. Moberg Volar Flap Advancement Keep NV pedicle thus move dermis with sensation Problems FFD – only advance 1cm Best in thumb ( more skin, less prone to FFD) Necrosis Can reduce blood supply to flexor tendon ( ?sig) Preserves length and finger sensitivity

26. Thenar Flap vs Cross Finger Pedicle Volar skin loss with exposed FDP Young pts with no OA index and middle – thenar flap better Ring or little -cross finger flap better

27. Thenar Flap Index & middle only Risk of PIP joint contracture Best if age < 30 Do not use in: –Dupuytren’s –RA

28. Thenar Flap Gatewood 1926 Smith & Albin H-flap Good tissue Good cosmesis

29. Cross Finger Pedicle Flap Palmar Oblique When others not possible but need to preserve length Can get excellent reinnervation Preserve paratenon so can skin graft on to it Release bridging pedicle at 3/52 Nishikawa 92% Satisfactory 50% cold sens None had normal sens 60% donor cold sens 50% stiffness 50% poor cosmesis

30. Type III >50% of phalanx lost –primary shortening and closure Allows immediate mobilisation

31. Type III - Amputation Fashion bone into a tuft-like tip Dissect nerves and cut short Don’t suture Flex  Ext – get reduced excursion especially ulna 3 fingers –quadriga effect and  reduced ROM and power Complications Intrinsic-plus finger as the free FDP and it’s lumbrical retract, increasing tension in the lumbrical and its contribution to the intrinsic extensor of the IPJ Thus active flexion  PIP extension

33. Outcomes Some cold intolerance in 30 – 50% adults with pulp loss 30% have altered sensation This is regardless of the type of treatment Possibly worse outcomes following skin grafting

34. Conclusions Aims of treatment of fingertip injuries –Provide a useful pain free tip with good sensation –Provide an acceptable cosmetic result

35. Conclusions Many techniques have been described for managing finger tip amputations Use the simplest appropriate method Nail bed injuries need accurate repair and a stable base

36. Recent Literature

37. References Roberts JO, Fenton OM. Management of Fingertip Injuries. Hospital Update 1988 Kleinert et al. The Deformed Finger Nail, a Frequent Result of Failure to Repair Nail Bed Injuries. J of Trauma 1967;7:177

38. References Green DP, ed. Operative Hand Surgery. Vol 1&2.London: Churchill Livinstone 2005 Smith, P. Lister’s the Hand Diagnosis and Indications: Churchill Livinstone 2002