FINGER TIP, NAIL BED
AND NAIL PLATE
INJURIES
INTRODUCTION
• Fingertip injury is any soft tissue, nail or bony
injury distal to insertion of the long flexor and
extensor tendon of a finger or thumb.
• Acute fingertip and thumb injuries are common
and require prompt and meticulous repair.
EPIDEMIOLOGY
• Can affect all ages but common in working
class adults and children.
• In adults
– Sharp Laceration (Most common)
– Crush & Avulsion injuries
• In children
– Most injuries arise at home and due to
jamming/crushing by doors
CLINICAL PRESENTATION
• Physical Examination
– Inspection
• Crush vs Sharp injury
• Presence or absence of exposed bone
• Red line sign
• Ribbon sign
• Nail or Nail bed involvement
• Viability of tip
• Presence of foreign body
– Range of motion
• Flexor and Extensor tendon involvement
CLINICAL
PRESENTATION
• Imaging
– AP& Lateral Radiograph to assess the bony
involvement.
ALLENS
Type
CLASSIFICATION
Feature
Type I Involving pulp only
Type II Pulp & Nail bed
Type III Distal phalanx fracture with pulp & nail bed
Type IV Lanula, Distal phalanx fr, Pulp & Nail bed
CLASSIFICATION -
PNB(2000)
Evan & Bernadis
Too complex for daily clinical use
NAIL AND NAIL BED
ANATOMY
• Perionychium -nail bed, paronychium.
• Paronychium -lateral skin surrounding the nail bed
and nail.
• Hyponychium – keratin plug
• Nail wall - skin over the dorsum of the nail fold.
• Eponychium- Extension of the nail wall distally
onto the dorsum.
• Cuticle or nail vest - eponychium is attached to the
nail by a cornified material.
• Lunula - The white, convex opacity extending
distally from beneath the eponychium, which is the
SUBUNGUAL HEMATOMA
• Injury to the nail bed, causing bleeding beneath the
nail.
➢ Separation of the nail from the nail bed.
• The pressure of bleeding in this closed space
frequently results in throbbing pain.
TREATMENT
• Small and asymptomatic hematomas (<50%) can be
-
-
observed.
• Repair of the nail bed was advocated with a
hematoma >50% and an associated distal phalanx
-
-
fracture.
• There is insufficient evidence to justify nail removal
and nail bed exploration in patients who present
with the acutely painful traumatic subungual
haematoma with an intact nail and nail margin, even
in the presence of a distal phalangeal fracture
CONCLUSION
• Leaving the nail in place is recommended for most
subungual hematomas with an intact nail.
• Exceptions may include children or patients with
concern for an optimally aesthetic nail.
• If the nail is broken or the edge disrupted, removal
of the nail and exploration of the nail bed are
advised.
• The acutely painful subungual hematoma should be
decompressed, whether done by trephination or nail
-
removal.
-
LACERATIONS
----
TREATMENT
• The nail plate is gently removed from the nail bed
with a small periosteal elevator or iris scissors.
• Careful removal of the nail is important to avoid
further injury to the nail bed.
• Once removed, the nail is scraped to remove
- -
residual soft tissue, then
-
-
soaked in povidone-iodine
(Betadine) solution.
-
• The nail bed is examined with loupe magnification.
-
NAIL BED REPAIR
• The nail bed handles like wet tissue paper.
• Each suture should be thrown with two bites.
-
• Be conservative with the placement of sutures.
• The goal is simple – re-approximation.
-
• Tension on the nail bed suture line will lead to
-
-
excessive scarring.
-
SIMPLE LACERATIONS
①• Ragged edges – leave let the nail mould them
• Undermining of edges upto 1mm done and
⑭ - -
reapproximated with 7’0 absorbable suture to avoid
- -
--
tension during closure.
COMPLEX STELLATE
LACERATIONS OR CRUSH
INJURIES
•Small fragments should be gently removed with a
-
-
periosteal elevator and used as a nail bed graft.
-
• A split- or full-thickness nail bed graft up to 1 cm in
-
diameter will usually survive, even when it is
-
placed directly on the distal phalanx cortex.
-
• Blood supply to the graft is established by
inosculation and vascular ingrowth from the
-
periphery.
• Split-thickness nail bed graft may be harvested
-
- -
from an adjacent noninjured finger or an amputated
-
finger.
-
AVULSION INJURIES
• Occurs at the level of the
germinal matrix and
proximal nail fold,
leaving a distally based
nail bed flap of germinal
or sterile matrix
• The nail bed remains
attached to the nail
• The nail fold is exposed
with unilateral or bilateral
-
incisions perpendicular to
- -
the lateral corners of the
-
eponychium.
-
• The incisions should be
-
made at a 90° angle to the
-
-
eponychium to prevent a
-
-
notch deformity
-
-
• If the laceration
-
occurs at the junction
-
-
of the ventral and
-
dorsal roof of the nail
-
fold, suture
-
approximation may
- -
not be possible.
-
• Horizontal mattress
-
stitch is placed
through the proximal
end of the avulsed
nail bed and brought
NAIL PLATE REPLACEMENT
• Trim the nail plate of sharp contours.
• Place the nail plate under the eponychial fold for a
distance of 2–3 mm.
-
• An absorbable
-
-
suture can be used to hold the nail
plate in place as an alternative to nylon. This will
- -
avoid painful suture removal.
-
Postoperative care
• The fingertip is dressed with nonadherent gauze, 2-
inch roll gauze, and a four-prong splint to protect
the repair.
• At 3–7 days after repair, the holding suture is
removed, especially if it is in the proximal nail fold
position.
PULP
• Fingertip injuries should be thoroughly irrigated and
debrided of foreign material and nonviable tissue
before closure is attempted.
• If the entire defect cannot be closed primarily, the
wound can be partially closed and the remainder
allowed to heal by secondary intention.
• Wounds up to 2–3 cm may be allowed to heal by re-
- -
epithelialization, but both surgeon and patient must
-
be aware that closure may take- 4–6 weeks.
• Secondary intention -improved contour, sensation,
-
-
and lack of donor site morbidity.
• Wound should be closed with a chromic or other
resorbable suture.
• Nylon sutures in the fingertip are not usually
necessary; they are uncomfortable to remove in the
early follow-up periods.
• The wound is covered with a non-stick dressing
like Xeroform or other minimal adherence
dressing.
• Daily dressing changes permits rapid wound
healing.
• Early motion is encouraged to prevent stiffness at
SKIN GRAFTING
• Defect is limited to skin
• Split- or full-thickness skin graft
• SSG – Contraction ,poor innervation and protective
function.
CAP OR COMPOSITE GRAFT
• CAP GRAFT - amputated part may be replaced as a
composite graft after defatting.
• Cap grafts are most successful for Zone I and II
-
sharp or blunt-cut injuries.
• Zone III or IV injuries regardless of mechanism
should be treated by another method.
• Better results seen in Children.
-
Cap or Composite graft
• Complete take (7.7%), Partial take (59%) and
(33.3)% had total loss of the graft.
• Despite this seemingly poor overall success of
composite grafts, only 10% of patients went on to
require a secondary procedure.
• Indications- patient/family dissatisfaction,
persistent pain, or aesthetic deformity.
• Composite graft placed on a fingertip that does not
revascularize should be left as a biologic dressing
to allow healing from below the eschar.
• This often leads to an adequately contoured
LOCAL FLAPS
Volar V–Y advancement (Atasoy, Kleinert)
• INDICATIONS - Fingertip defects less than one
centimeter ,dorsal oblique or transverse fashion
• Flap is oriented as a triangle and closed in a V–Y
fashion.
• The base of the triangle sits at the wound edge and
- -
the apex at the DIP crease.
-
• This skin is incised down through the dermis and
then scissor dissection is used to release fibrous
septae that anchor glabrous skin to the deeper
musculoskeletal structures.
• The most distal corners of the flap must be freed by
2–3 mm in order to allow adequate release of the
flap distally.
• Similarly, the apex of the flap at the DIP joint must
be released significantly to permit distal migration
of the flap.
• The flap is elevated with its neurovascular pedicles
on either side of the flap in the plane of flexor
Atasoy V-Y Advancement Flap
• 0.75–1 cm of length can be obtained with a volar
V–Y advancement flap.
• Functional and cosmetic results are extremely good
as this flap remains one of the most important tools
in treatment of fingertip injury closure
Lateral V–Y advancement flaps
(Kutler)
• INDICATION- Transverse and lateral oblique
defects
• The dorsal incision is deepened down to the bone
and then moves anteriorly beneath the flap.(leave
millimetre of skin at the margin of the nailfold)
• The volar incision is only carried through skin and
takes in approximately one-third of the skin margin
of the defect at the end of the finger
• Once the two flaps are mobile they are sutured to
each other and in the midline to the remains of the
nail otherwise the joined flaps tend to prolapse in a
volar direction
Kutler V-Y Advancement
Flap
Visor flap
• INDICATION- Transverse distal fingertip
amputations with exposed bone
• The visor flap –bipedicled, dorsal aspect of the
finger.
• Raised at the level of the paratenon.
• The width of the flap is approximately that of the
fingertip defect.
• The flap is sensate and vascularized by branches of
the volar digital arteries & nerves.
• Back cuts in the dorsal aspect of the skin may be
required for transposition of the flap.
• The donor site requires a skin graft.
• If dog ears are present, they are left in place and
Homodigital flaps
• Reconstruction of skin and pulp loss at the
fingertip, or skin loss over a flexor tendon.
• When planning the flap a digital Allen test should
be used to confirm that both arteries are adequate.
• The flap is raised from the side of the proximal
phalanx (distal two-thirds), but may be extended
proximally to encroach on part of the web skin.
• From the planned skin island a zig-zag incision is
made to the distal defect.
Reverse digital artery island flap
• With a tourniquet on the arm the volar and
proximal margin of the flap is incised first and the
digital artery located and ligated at the proximal
margin.
• Release the tourniquet and check the blood supply
to the digit through the contra lateral vessel at this
point before finally dividing the artery.
• The remainder of the flap is incised and dissected
off the proper digital nerve either dividing the
dorsal nerve branch and taking it with the flap or
leaving the branch on the finger.
• At the distal end of the flap it is important to leave
Reverse Digital Artery Island
Flap
• If harvesting the flap with the dorsal branch of
nerve for an innervated fingertip reconstruction
then it is worth dissecting this out proximally so as
to have up to 2 cm projecting from the flap for
microsurgical attachment to the damaged proper
digital nerve.
• Do not close the skin edges of the zig-zag incision,
particularly if a neurorrhaphy has been carried out.
• Close the donor area with FTG
Volar advancement flaps on the
thumb
MOBERG FLAP
• A volar oblique injury to the tip of the thumb is the
classic indication for this flap.
• The volar skin of thumb is supplied by digital
arteries.
• Dorsal skin is supplied by separate vessels - the
ulnodorsal vessel being a branch of the first dorsal
metacarpal artery and the radiodorsal vessel a
branch of the radial artery.
TECHNIQUE
• Mid lateral incision dorsal to neurovascular
bundles.
• Flap dissected off flexor tendon sheath
• Advanced of the palmar skin
• Helped with some IP flexion
MOBERG ADVANCEMENT
FLAP
DELLON MODIFICATION
• Flap elevation can extend proximally onto the
thenar eminence, allowing coverage of wounds 3
-
cm in size.
-
Bipedicle island advancement
(O’ BRIEN)
• Transverse incision at the level of the proximal
third of the proximal phalanx taken through skin
only.
• The neurovascular pedicles are then dissected out
from beneath the proximal flap to permit
mobilisation of me distal skin island.
• This island is then advanced and the secondary
defect filled with a full thickness skin graft.
Unipedicled rotation-advancemen t
flap (HUESTON)
• With smaller defects (8 mm) it may be possible to
avoid bilateral mid-axial incisions and carry out a
rotation advancement of the volar thumb skin based
only on the vascular pedicle of one side
• The base of the flap is classically positioned on the
ulnar side of the thumb so as to preserve maximum
innervation to the ulnar side of the reconstructed
tip.
HUESTON FLAP
FOUCHER MODIFICATION
Thumb radiodorsal neurovascular
flap (Pho)
• Dorsal branches of the radial palmar digital artery
given off at the level of the neck of the proximal
phalanx of the thumb.
• The dorsal margin of the flap passes dorsally from
the defect some 3 mm away from the nail edge,
taking as much as necessary over the dorsum, and
then curves down to the mid-lateral line at the
proximal third of the proximal phalanx.
• The volar margin follows the edge of the pulp
defect and then approaches the mid-lateral line
along which an incision is made to the metacarpal
head to expose the pedicle.
Advancement flaps of the digits
Unipedicled island advancement
flap (Venkatswamy)
• lateral or medial oblique tip loss by advancing a
triangular island flap from the less damaged side.
• The base of the flap is as wide as the defect and the
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other two sides are 2 to 21/2 times long as base.
-
• The dorsal incision is deepened to a plane beneath
the subcutaneous fat so that the neurovascular
bundle is raised with the flap.
• On the volar side the incision is through skin, and
fibrous septa are divided with scissors preserving
vessels and nerves entering the volar side of the
triangle.
Unipedicled island advancement
flap (Venkatswamy)
Dorsolateral island advancement
flap (JOSHI)
• Neurovascular island flap from the dorsum and
lateral aspect of a finger.
• The volar margin of the flap borders the defect and
then tapers towards the mid-lateral line at the PIP
joint crease.
• The dorsal margin of the flap passes from the defect
past the proximal corner of the nail, about 3 mm
from it, reaches the midline on the dorsum of the
finger and then tapers down to meet the volar
incision at the PIP joint crease.
• The dorsal incision is made and attempts made to
retain a dorsolateral vein at this point .
• The flap is advanced with the MCP joint flexed and
the donor site reconstructed with a full-thickness
graft.
Dorsolateral island advancement
flap (JOSHI)
Step advancement island flap
(Evans)
• Advancement – without secondary defect
• The volar margin of the flap is designed as three
triangles, narrow proximally and wide distally, with
only the distal flap crossing the midline.
• The dorsal incision is slightly convex and tapers
proximally to meet the volar incision at a point
overlying the neurovascular bundle.
• Complete apposition of dorsal skin edges is avoided
if this would mean putting the flap under tension
and any gaps heal secondarily.
Step advancement island flap
(Evans)
BipedicIed island flap (O'Brien)
BipedicIed island flap (O'Brien)
• Mid-lateral incisions reach from the edges of the
defect to the PIP joint.
• Transverse incision is made through skin only and
the neurovascular bundles further mobilised from
beneath the proximal skin.
• Lateral ' ears' at the end of the flap are joined
together in the mid line, a very adequately rounded
and projecting pulp is obtained.
Oblique dorsal flap (Flint &
Harrison)
• Good sensation because the palmar digital nerve
gives branches of supply to the skin over the
dorsum of the DIP joint and these branches are
included in the flap together with adjacent branches
of the digital artery.
• The proximal incision runs from the PIP joint
crease at the mid-lateral line,obliquely across the
dorsum of the finger to the DIP joint crease on the
opposite side.
• The distal incision is placed parallel with this and
sufficiently far away to provide enough width of
skin to resurface the front of the finger .
Oblique dorsal flap (Flint &
Harrison)
THENAR FLAP
• Based on the radial aspect of the palmar thenar
crease.
• It is most often utilized for the index and long
fingers because of their proximity to the thumb
• Defects upto 1.5cm (Primary closure)
• Care must be taken not to injure the neurovascular
bundles that lie immediately beneath the
fasciocutaneous thenar crease flap.
• The injured finger must be flexed at the PIP and
often the DIP joint in order to allow flap inset.
Beasley -four guidelines
1. The metacarpal phalangeal joint of the recipient
finger is fully flexed in an attempt to limit
required flexion of the PIP joint
2. The thumb is placed in full palmar abduction or
opposition
3. The flap is designed with a proximal pedicle
high on the thenar eminence so that its lateral
margin is at the metacarpophalangeal skin crease
4. The pedicle is divided after 10 to 14 days
THENAR FLAP
Thenar
Flap
HETERODIGITAL FLAPS
CROSS FINGER
• The rectangular flap is raised on the dorsum of a
finger middle phalanx with the base of the flap
along the medial or lateral side and the flap turned
over through180degree.
• Division of Cleland's ligaments in the base of the
flap improves its mobility.
CROSS FINGER FLAP
VARIATION
• Longitudinally oriented flap over dorsum of middle
phalanx with distal base.
• The distal based flap has good blood supply enters
it from the superficial arcade over the base of the
distal phalanx but it is advisable to restrict the
length-to breadth ratio to 1.5 to I.
Innervated cross finger flaps
Innervated cross finger flaps -
Thumb
REVERSE CROSS FINGER FLAP
• This flap consists of subcutaneous tissue elevated
from the dorsum of the middle phalanx of the
adjacent finger.
• This is exposed by first elevating the skin of the
donor digit in this region, maintaining a base
laterally, on the side opposite the injured digit.
• The flap is turned over to cover the dorsal defect of
the injured finger.
• The elevated skin from the donor digit is then
sutured back into its native position and the flap on
the injured digit is skin grafted.
Heterodigital neurovascular island
flaps (Littler)
• Neurovascular island flap
utilizes the donor skin from
the ulnar aspect of the long
or ring finger to provide
sensate vascularized tissue
to a given recipient site.
Heterodigital neurovascular island
flaps (Littler)
• Arteriograms and digital Allen’s tests have been
advocated prior to performing this flap to confirm
an adequate co-dominant arterial supply to the
donor and adjacent finger.
• Before ligating and dividing the contralateral
branch, a temporary clip should be applied, the
tourniquet released, and the viability of the finger
verified.
• Creating chevron incisions lateral to the DIP and
PIP creases is important to prevent contractures at
these joints following healing of the skin graft.
COMPLICATIONS
• Donor site - stiff fingers with contractures
• Cortical relearning or plasticity
FDMA (First Dorsal Metacarpal
Artery Flap)
• Reconsttuction of ulnar side defects of the volar
thumb pad.
• Skin and subcutaneous tissue of the proximal
phalanx of the index finger
FDMA (First Dorsal Metacarpal
Artery Flap)
• The first dorsal metacarpal artery supplies
vascularity in the vena comitantes and some
superficial veins supply the venous outflow of the
flow.
• Branches of the superficial radial nerve provide
sensibility to this flap.
• The flap is elevated at the plane above the
paratenon
• The rest of the pedicle is dissected and the flap can
either be transposed through a tunnel or through a
zig-zag incision into the volar thumb defect.
BONE
Distal phalanx fractures
• Distal phalanx fractures are found in approximately
50% of nail bed injuries and result in a higher
incidence of secondary nail deformities.
• X- RAY IS A MUST ( MINIMUM 2 VIEWS)
Seymour fracture
• Seen in children with the appearance of an
elongated nail.
• The fracture occurs through the physis with
interposed soft tissue, usually consisting of nail bed
matrix but can include other tissues, like
eponychial fold.
TREATMENT
• Reduce the fracture and fix it with k- wire
• Repair the nail bed
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