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What’s New in Fingertip Injuries Gordon A. Brody, MD SOAR Redwood City Goals of Treatment • • • • • 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 • • • • 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. • • 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 • • • • • • 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!