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Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous...

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Fingertip Injuries Anthony Perera Andy Mahon
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Page 1: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

Fingertip Injuries

Anthony PereraAndy Mahon

Page 2: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

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

Page 3: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

Surgical AnatomyGerminal 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.

Page 4: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

Fingertip Injuries

• Subungual haematoma

• Nail bed laceration• Distal phalanx fracture• DIPJ dislocation• Mallet finger• FDP rupture

Page 6: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

Nail Bed Injury Classification

I -Small haematoma (>25%)II -Large haematoma (>50%)III -Laceration + FractureIV -Nail bed FragmentationV -Nail bed Avulsion

+/- paronychium+/- whether it involves S or G

matrix

Page 7: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

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)

Page 8: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

Principles of Operative Management

1. Remove nail2. Reduce and fix # 1st(K wire

or figure of 8 suture) 3. Open corners of dorsal nail

fold to improve view4. Replace all of nail bed and

accurately repair5. When all nail bed not

available consider grafting6. Clean nail and replace ( or

use foil packet)7. Either trephine or use glue8. Repair dorsal fold (or

appropriate graft)

Page 9: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

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

Page 10: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

Post –Op ManagementDressing 7-10 dys –protect nailStart desensitsation at 2/52Move immediatel unless #K wire out at 4/52New nail pushes old one out at 2-3 weeks

Complications• Non-adherence or ridging of plate• Split nail• Crooked nail plate• Hooked nail

Page 11: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

Dealing With Complications

1. Non-adherence/ ridgingDue to granulation tissue from poor repair of nail bedRx –scar excision

2. Split NailDue to longitudinal scar in matrixRx –excise and graftDue to adhesionsRx –graft and stent apart

3. Crooked Nail PlateDue to sterile matrix contracture on 1 sideRx –excise and full thickness graft

Page 12: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

Dealing With Complications

4. Hooked NailDue to insufficient bony supportRx – AVOID, don’t use nail bed to cover partial amputationDistal edge of sterile matrix should be at least 2mm from distal edge of bonecan shorten nail bed or release it distally to allow retraction proximally

If uncorrectable nail deformity -can fully excise and use full thickness skin graft

Page 13: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

Fingertip Injuries

Goals of Treatment1. Preserve Function2. Durable coverage3. Preserve useful sensibility4. Prevent symptomatic neuromas5. Prevent joint contracture6. Shorten recovery7. Reduce morbidity8. Preserve length –especially thumb

Page 14: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

Fingertip Injury Classification

Page 15: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

Management

Type I Primary ClosureSecondary healingComposite graftsSplit thickness skin graft

Type II Shorten and closeCoverage

Type III Amputation

Page 16: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

Type I -1O Closure + 2O Healing

Equivalent Results

Primary – if no tension

Secondary – if <1cm and no exposed bone, volar cuts

?pulls in innervated tissue

Page 17: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

Conservative Management

• Patients / parents may need convincing

• Some doctors too!• Before and after pictures of example

cases• Particularly in children• Das, Brown 1978

Page 18: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

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

Page 19: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

Type I- 2OHealing vs Grafting

Holm and Zachariae- 5 year FU2O STSG

Good 90% 50%Cold Sens 39% 33%Dec Sens 26% 67%Pain at Site 71%Return to work IncComplications Inc

Mennem and WieseEven if bone exposed near normal shape, useful epithelium,

no complications, no hook nail, excellent sens

Page 20: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

Type II

1. Shorten and conservative2. Shorten and close, see at 2-3 days

? AntibioticsManual labourers- return to work 6-8 weeksIf not enough bone then trim nail bed back to avoid hook nail.

3. If important to preserve length – need coverage

Page 21: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

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

Page 22: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

Advancement Flaps

• Nice technical exercises!• Preserve length• Originators results seem better than

others

Page 23: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

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-dyaesthesia40% cold sens50% difficulty with grasping

Page 24: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

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

Page 25: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

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

Page 26: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

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

Page 27: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

Thenar Flap

• Index & middle only

• Risk of PIP joint contracture

• Best if age < 30

• Do not use in:– Dupuytren’s– RA

Page 28: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

Thenar Flap

• Gatewood 1926• Smith & Albin H-flap

• Good tissue• Good cosmesis

Page 29: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

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 sensNone had normal sens60% donor cold sens50% stiffness50% poor cosmesis

Page 30: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

Type III

>50% of phalanx lost –primary shortening and closure

Allows immediate mobilisation

Page 31: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

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

Page 32: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.
Page 33: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

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

Page 34: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

Conclusions

• Aims of treatment of fingertip injuries– Provide a useful pain free tip with good

sensation– Provide an acceptable cosmetic result

Page 35: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

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

Page 36: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

Recent Literature

Page 37: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

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

Page 38: Fingertip Injuries Anthony Perera Andy Mahon. Nail Bed Anatomy Nail –keratinised squamous epithelium, acts as protective plate and increases sensitivity.

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


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