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Fingertip Injuries: Evaluation and Treatment

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Fingertip Injuries: Evaluation and Treatment Fingertip Injuries: Evaluation and Treatment Paul R. Fassler, MD Abstract The primary goal of treatment of an injury to the fingertip is a painless fingertip of the distal phalanx and consists of with durable and sensate skin. Knowledge of fingertip anatomy and the available the sterile and germinal matrices. techniques of treatment is essential. For injuries with soft-tissue loss and no ex- The germinal matrix is located prox- posed bone, healing by secondary intention or skin grafting is the method of choice. imally and forms the ventral floor of When bone is exposed and sufficient nail matrix remains to provide a stable and the nail fold. Its distal margin is de- adherent nail plate, coverage with a local advancement flap should be considered. fined by the white semicircular area If the angle of amputation does not permit local flap coverage, a regional flap near the base of the nail, known as (cross-finger or thenar) may be indicated. If the amputation is more proximal or the lunula. The germinal matrix if the patient is not a candidate for a regional flap because of advanced age, os- produces 90% of the thickness of the teoarthritis, or other systemic condition, shortening with primary closure is pre- nail plate; however, the nail plate is ferred. Composite reattachment of the amputated tip may be successful in young not adherent to the germinal matrix. children. The outcome of nail-bed injuries is most dependent on the severity of in- The sterile matrix, the portion of the jury to the germinal matrix. nail bed distal to the lunula, is ad- J Am Acad Orthop Surg 1996;4:84-92 herent to the nail plate and con- tributes little to its thickness. The dorsal skin over the nail fold is called the nail wall. The distal mar- Fingertip injuries, defined as those justified for some injuries of the gin of the nail wall, which adheres distal to the insertion of the flexor thumb, including those in children. to the nail plate, is called the epony- and extensor tendons, are the most chium. The matrix tissue that forms common injuries of the hand. Al- the dorsal roof of the nail fold pro- though maintenance of length, Anatomy of the Fingertip vides shine to the nail plate. preservation of the nail, and appear- ance are important, the primary goal Knowledge of fingertip anatomy1 is of treatment is a painless fingertip essential for optimal treatment of in- General Principles of with durable and sensate skin. Con- juries. The skin covering the pulp of Evaluation and Treatment siderable hand dysfunction results the finger is very durable and has a when a painful fingertip causes the thick epidermis with deep papillary Evaluation of a patient with a finger- patient to exclude the digit from use. ridges. The thick skin beneath the tip injury begins with taking a history Treatment must be individualized distal free edge of the nail plate is of the mechanism of injury and im- on the basis of many patient-related called the hyponychium. The pulp factors and specific wound charac- consists of fibrofatty tissue that is teristics. Methods of treatment in- stabilized by fibrous septa extending Dr. Fassler is Clinical Instructor, Department of clude healing by secondary from the dermis to the periosteum of Orthopedics, University of Cincinnati College of intention, skin grafting, shortening the distal phalanx. Medicine. of the bone and primary closure, and The nail complex, or perionych- coverage with a local or regional ium, includes the nail plate, the nail Reprint requests: Dr. Fassler, Cincinnati Hand flap. Composite reattachment bed, and the surrounding skin on Surgery Consultants, 2800 Winslow Avenue, Suite 401, Cincinnati, OH 45206. should be considered for fingertip the dorsum of the fingertip (paro- amputations in young children. Al- nychium) (Fig. 1). The nail bed is Copyright 1996 by the American Academy of Or- though microsurgical replantation is adherent to the very thin perios- thopaedic Surgeons. not indicated in most cases, it may be teum over the distal two thirds or so 84 Journal of the American Academy of Orthopaedic Surgeons Paul R. Fassler, MD cal options are discussed in the fol- Insertion of extensor tendon Nail wall lowing sections. Nail bed Soft-Tissue Loss Without Dorsal roof Nail fold Exposed Bone Hyponychium Ventral floor Distal interphalangeal joint Appropriate treatment for loss of skin or pulp tissue without exposed bone is either to perform a skin graft or to allow the wound to heal by sec- Periosteum ondary intention. Controversy exists Fig. 1 The anatomy of the nail bed in sagittal section. as to which is method is better. Most agree that smaller wounds (those no larger than 1 cm2) should be treated nonoperatively by the open method; portant patient-related factors, such field is essential to allow inspection however, the size of the defect rela- as age, gender, handedness, occupa- and repair of the wound. A Penrose tive to the size of the finger must be tion, avocation, and history of previ- drain clamped around the base of the taken into consideration. ous hand problems and systemic finger is convenient, but other de- The primary advantage of the open diseases. A complete hand examina- vices, such as a pneumatic digital technique is its simplicity. Several au- tion includes assessment of the skin, sleeve, a wrist tourniquet, or a blood thors have reported superior results, vascularity, neurologic function, and pressure cuff placed around the fore- high patient satisfaction, and few flexor and extensor tendon function. arm, can also be used. The wound complications with this method.2,3 The injury site is inspected with spe- should be closely inspected after it Complete healing usually takes 3 to 5 cific attention to the characteristics of has been thoroughly irrigated and weeks and occurs by wound contrac- the wound. Radiographs of the fin- debrided of all nonviable and conta- tion and epithelialization. About 7 to ger are obtained to assess the extent minated soft tissue. It is critical to re- 10 days after the injury, the patient is of bone injury. Intravenous anti- member that in the severely crushed instructed to begin soaking the finger biotics are given to patients with a fingertip, the full extent of the injury in a warm water–peroxide solution fracture, and appropriate tetanus may not be evident until the wound once a day and to apply a light ban- prophylaxis is provided. has been meticulously debrided, dage and fingertip protector. Range- Once the patient and wound have which then necessitates modification of-motion exercises are encouraged. been completely assessed, a treat- of the original treatment plan. When the wound is completely epi- ment plan is formulated. If more The specific wound characteris- thelialized, a home program of desen- than one option is available, the ad- tics determine which method of sitization is initiated. vantages and disadvantages of each treatment is optimal for a given Larger wounds treated nonopera- should be discussed with the pa- patient. It is important to know tively heal with a thin layer of epithe- tient, and the simplest method that whether there is loss of skin or pulp lium that is not very durable, and accomplishes the desired result tissue and the amount of such loss, application of a skin graft should be should be selected. as well as whether there is exposed considered. Skin grafts applied to the Many fingertip injuries can be bone, a distal phalangeal fracture, palmar surface of the fingertip should managed in a well-equipped emer- or injury to the nail bed or peri- be full thickness because they contract gency department, but complex re- onychial tissue. In the case of am- less, are more durable and less tender, gional flaps are more appropriately putation, it is important to establish and achieve better sensibility than treated in a formal operating room. A the level and angle of injury. For split grafts. The hypothenar area is digital block placed at the level of the wounds with no soft-tissue loss, the preferred donor site, as it is con- metacarpal head is a convenient simple closure is all that is needed. venient and the skin is durable and an method of obtaining analgesia. A Viable skin flaps are loosely su- excellent color match, similar in qual- wrist block can be used when more tured, and a splint is applied if a ity to the skin of the pulp.4 than one digit is injured. The entire fracture is present. The skin graft is taken from the hand and forearm are prepared and The treatment of specific types of hairless area of the ulnar border of draped in sterile fashion. A bloodless injuries and the use of various surgi- the hand. The width of the graft Vol 4, No 2, March/April 1996 85 Fingertip Injuries can be as much as 2 cm. The donor sterile matrix remains (less than 5 brought over the end of the bone and site is closed primarily. The graft is mm) to produce an adherent, stable sutured to the dorsal skin. If the an- sutured over the defect, with a few nail.6 Patients who are of advanced gle of the amputation is oblique in sutures left long so that a moist cot- age or who have a systemic condi- the sagittal plane, the side with the ton ball can be secured over the tion and in whom, therefore, a re- long skin flap is used to cover the graft to help maintain coaptation gional flap is contraindicated should bone. Excess skin (e.g., dog-ears) with the underlying tissue. The undergo a revision amputation usually needs to be trimmed to ob- cotton ball is removed after about 7 when open treatment, skin grafting, tain satisfactory contour and ap- days, and range-of-motion exer- or local flap coverage is not possible.
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