Download Fingertip Injuries

What’s New in Fingertip Injuries
Gordon A. Brody, MD
SOAR
Redwood City
Goals of Treatment
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Durable
Sensate
Aesthetic
Preserve Length
Preserve Mobility
Goals of Treatment
• Pain and Worker’s Compensation are the most
important factors in determining RTW after
finger injuries
– Significant predictors of DASH
• Job burnout/satisfaction less important
– J Hand Surg 2012;37A:1812-1819
Assessment
• Angle of Loss
• Percentage nail preserved
– <50% leads to hook nail deformity-ablate
• Bone exposed?
• Size of defect?
Treatment
• Open Wound Management
– No bone exposed
– Wounds <1cm
– Simple, best in children
– Sensate, similar skin
– Reduced padding, tender stump
– 3-6 weeks to heal
Treatment
• Composite Graft
– Age <2years
– Biologic dressing in adult
– Undpredictable
Treatment
• Skeletal Shortening, Revision Amputation
– Never shorten thumb
– Quick recovery
– Proximal to lunula should ablate nail
– Laborers, heavy contamination
Treatment
• Skin Graft
– Preserved padding present
– Wound >1cm
Local Flaps
• V-Y Flap
– Transverse/Palmar Oblique
– Distal transverse defects
– >50% nail preserved
– Durable, sensate
– Up to 10 mm. distal edge advancement
– Volar V-Y better than lateral Kutler
Local Flaps
J Hand Surg 2012;37A:1806-18011
Pivot Flap
Pivot Flap
• Excellent sensory recovery at 2 mos.
• Mild cold intolerance
• No painful tips
Local Flaps
J Hand Surg 2011;36A:129-134
Step-Advancement Flap
Step-Advancement Flap
Step-Advancement Flap
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No need to shorten bone
Near normal ROM
Static 2-pt is 3 to 5 mm
No donor site morbidity
Local Flaps
J Hand Surg 2013;38A:350-356
IDAP Flap
IDAP Flap
• Larger defects than V-Y
– 3.5 x 2 cm
• Excellent sensation (close to opposite hand)
• No joint contractures
Moberg Flap
• Thumb only
– Dorsal skin has independent blood supply
– IP contracture for defects >1.5 cm
Heterodigital Flaps
• Cross Finger
– Large wounds, exposed bone
– Release Cleland’s ligament
• Thenar Flap
– Index/Middle only
– Best <40 yo
– RDN at risk
FDMA Flap
• Ideal for thumb coverage
• 1st. Dorsal MC Artery is branch of radial artery
• 2 pt. 11 mm
– Requires cortical reorientation
• Good donor site
Question
• The arterial supply of the flap shown in Figures 1
and 2 is:
• A. First dorsal metacarpal artery
• B. Dorsal antebrachial superficialis artery
• C. Second common digital artery
• D. Deep to the aponeurosis
• E. Supplying terminal skin on the dorsum of the
index finger at the level of the middle phalanx
Question
• Preferred Response: A
• Discussion: This patient underwent treatment with a kite flap. The first
dorsal metacarpal artery provides the blood supply for this flap. It is a very
predictable and constant artery that arises from the radial artery. Foucher
and Braun noted only 2 of 30 dissections demonstrated that it arose from
the dorsal superficial antebrachial artery. It lies primarily on the dorsal
radial side of the index finger. Its terminal skin supply is the dorsal aspect
of the proximal phalanx of the index finger. While some aponeurotic fibers
may cross over the artery, it lies on (superficial to) the aponeurosis.
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• References
• Foucher G,Braun JB. Anewislandflaptransferfromthe dorsum of the index
to the thumb. Plast Reconstr Surg 1979;63:344-9.
• Shi SM, Lu YP. Island skin flap with neurovascular pedicle from the dorsum
of the index finger for reconstruction of the thumb. Microsurgery
1994;15:145-8.
Question
• The palmar neurovascular advancement flap
(Moberg) is most appropriate for reconstruction
of which of the following defects?
• A)Thumb pulp
• B)Index finger pulp
• C)Thumb nailbed
• D)Thumb dorsum
• E)Index dorsal middle phalanx
Question
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Preferred response: A
Discussion: Use of the Moberg flap requires an independent dorsal blood supply
for digit viability as seen in the thumb but not predictably in the fingers. The
Moberg flap therefore is best used for volar pulp defects in the thumb of up to 1
cm (see Figures 1, 2, and 3). Additional advancement can be achieved by exposing
and mobilizing the neurovascular structures. Flexion contractures, a frequent
outcome of this mobilization, are better tolerated in the thumb than in the fingers.
Index finger pulp loss can be treated with the cross-finger flap. A flap from the first
dorsal metacarpal artery can be used to cover dorsal thumb defects, and defects
over the index dorsal middle phalanx can be covered using skin grafts or with the
extended dorsal metacarpal artery flaps. The Moberg flap does not have sufficient
length to cover nailbed defects.
References:
BaumeisterS,MenkeH,WittemannM,GermannG.Functional outcome after the
Moberg advancement flap in the thumb.
J Hand Surg 2002;27(1):105-114.
Friedrich JB, Katolik LI, Vedder NB. Soft tissue reconstruction of the hand. J Hand
Surg 2009;34(6):1148-1155.
Thank you!