SURGICAL MANAGEMENT OF FINGERTIP INJURIES

INCLUDING NAILBED & COMPLICATIONS / DEFORMITY

Christian Dumontier MD, PhD
Hand Center, Guadeloupe, FWI
Presentations can be downloaded at
www.diuchirurgiemain.org

I have nothing to disclose

 THE FINGERTIP

• Bony support

• Pulp: Sensibility, prehension

• Nail apparatus : Sensibility,

specialized organ

4.8 millions A+E visits in 2014-USA

2/3 paediatric hand injuries
 EPIDEMIOLOGY OF NAIL TRAUMA

• Epidemiological study (187 cases in 2 years) - About 8%

of all hand emergencies

• Associated lesions
Almost 70% of
• Pulp: 26,7%
associated
• Distal phalanx Fx: 15,5% lesions !
• Pulp lesion + Fx: 26,2%

• Another lesion on the nger/hand: 11,8%

Carmès S. Finger Nail Injuries in a Trauma Center Ann. Fr. Med. Urgence (2018) 8:359-362
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 NAIL TRAUMATOLOGY

• Anatomy & physiology

• Nail traumatology

• Post-traumatic nail dystrophies

www.diuchirurgiemain.org
https://www.youtube.com/watch?v=zt8x_sY4fn0
www.fessh.com
 NAIL TRAUMA - TO REMEMBER

• Crushing mechanism +++

• 50% of lesions were in the

distal part of the nail unit

• At least 65% needed a

surgical repair

Carmès S. Finger Nail Injuries in a Trauma Center Ann. Fr. Med. Urgence (2018) 8:359-362
 THE NAIL PLATE
• The peryonychium:

• All the tissues located

under the nail plate

• The paronychium:

• All the tissues located

over the nail plate
 THE PERYONYCHIUM

• Nail matrix (germinal)

• Nail bed (sterile)

• Hyponychium
 CLINICAL CONSEQUENCES

• The nail plate is so supple that it is often intact in nail

trauma

• It has to be removed to see and repair the lesions +

++
ALTHOUGH CONTROVERSIAL
• Every time it is possible replace the
nail plate. It allows:

• To « mold » the repair

• To protect it

• To limit pain during dressing

• To increase pulp sensibility

• But don’t forget to make a hole for

drainage (it’s obviously a foreign body)

Tos P et al. A simple sterile polypropylene ngernail substitute.Chir Main. 2009 Jun;28(3):143-5.
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 NAIL BED INJURY
• Remove the nail plate (re- x it or replace it at the end)

• Wash injured tissues

• No debridement

• Reduce and eventually x a fracture

• Repair the nail bed (6/0 sutures)

• One can expect > 90% good results for simple lesions

• Same principles apply for more severe injuries with less

satisfactory results
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 MATRIX INJURIES
• Principles are the same but
sequelae are always more severe:
ridges, cracks, or even nail loss
• To extend the incisions: use
Kanavel’s technique: 2 incisions at
the junction proximal-lateral fold
• Extend to the DIP if necessary
• The (potential) scar of the nail
plate will be hidden under the
lateral folds.
INJURIES TO THE PARONYCHIUM

• Better to use aps to

reconstruct the folds
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 FINGERTIP INJURIES
• Pulp anatomy
(www.diuchirurgiemain.org)

• Vascularisation of the ngertip

(www.diuchirurgiemain.org)

• Flaps of the ngertip

(www.diuchirurgiemain.org &
FESSH.com)
• Do not forget tetanus
• Fingertip injuries (Youtube) prophylaxy

• No antibiotics needed

• Pain killers needed

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 TECHNIQUES FOR PULP RECONSTRUCTION

Conservative
+
Easy, cost effective,
-
Nail deformities,
treatment ef cient scar tenderness
No sensibility (43%
Skin graft Availability
< 6 mm 2PD)
Infection, expensive,
Skin substitute No donor morbidity poor sensibility

Thickness, Sensible Dif cult

Flaps Avalaibility Complications
Very dif cult, depends
Replantation “normal” nger on mechanism

Reconstruction of
Toe transfer bone and soft-tissue
Very dif cult

Nail remnants, short

Stump plasty Easy, simple
nger, painful stump

Cold intolerance will be observed in almost all patients

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 CONSERVATIVE TREATMENT HAS PROVEN EFFICIENT AND SAFE !

• Starts with debridement under local

(except for Mennen’s technique
which retains growth factors)

• Repeated and controlled dressings -

between 3 and 29 in the literature

• Healing in 3-5 weeks

• Very few complications, sensibility

almost normal

• 90 to100% of good results

(except for the nail)

Giesen T, Adani R, Carmes S, Dumontier C, Elliot D, Calcagni M. IFSSH scienti c committee on skin coverage: 2015 report. Hand Surg Rehabil.
2016 Oct;35(5):307-319.
Lasserre G et al. [Fingertip reconstruction with occlusive dressing: clinical results and biological analysis of the dressing content’s].. Chir Main.
2010 Oct;29(5):315-20.
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 MENNEN’S TECHNIQUE
• Occlusive dressing

• Studies have shown that the dressing

retains growth factors (PDGF, VEGF, GF)

• True regeneration (no crust)

• Sonography has shown a pulp

regeneration close to 90%

Lasserre G et al. [Fingertip reconstruction with occlusive dressing: clinical results and biological analysis of the dressing content’s].. Chir Main.
2010 Oct;29(5):315-20.
Mennen U, Wiese A. Fingertip injuries management with semi-occlusive dressing. J Hand Surg Br. 1993, 18: 416-22.
Hoigné D, Hug U. Amputation de la dernière phalange. régénération par film. Forum med Suisse 2014; 14(18):356-360.
 WHAT ARE THE LIMITS TO CONSERVATIVE TREATMENT ?

• Good question ! Answer is difficult

• Comparative series report

identical or better results with
conservative treatment compare
to other techniques including flaps,
even if the bone is exposed !
Chow SP, Ho E. Open treatment of fingertip injuries in adults. J Hand Surg Am. 1982 Sep;7(5):470-6.
Ma GFY, Cheng JCY, Chan KT, Chan KM, Leung PC. Fingertip injuries- a prospective study on seven methods of treatment on 200 cases. Annals
Academy of Medicine 1982;11(2):207-13.
Soderberg T, Nystrom A, Hallmans G, Hulten J. Treatment of fingertip amputations with bone exposure. A comparative study between surgical
and conservative treatment methods. Scand J Plast Reconstr Surg 1983;17:147–152.
van den Berg WB1, Vergeer RA, van der Sluis CK, Ten Duis HJ, Werker PM. Comparison of three types of treatment modalities on the outcome
of fingertip injuries. J Trauma Acute Care Surg. 2012 Jun;72(6):1681-7
INDICATIONS = WHEN TO USE A FLAP ?
Is it possible to regain
• What do we expect ?
a normal or near
normal pulp, that is a
bulky, sensate, stable
and painless pulp ?

If not, consider
revision amputation
Wood router injury, 60 years old, non-dominant
hand, hungry to work rapidly
 I DEFINITIVELY WILL USE A FLAP !
• My indications are : • Among the various
• Coverage of a (large) loss
of substance that (may)
expose bone, exor tendon;
• Restore pulp sensibility
(normal 2PD is 2-3 mm);
• Sustain/protect/repair the
nail apparatus;
• Restore nger esthetic.
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possibilities, my questions
are :
• Which one will give me
the best functional result,
with the lesser morbidity ?
• Which one is the simplest
for me and for the patient
as well ?
• What am I able to do ?.
 SURGERY ALWAYS STARTS WITH A LARGE DEBRIDEMENT
AND A LAVAGE (WITH SALINE AND LOW-PRESSURE) !

• And then, you

will decide if you inadequate debridement, too small
ap = Surgeon’s mistake !
need a ap, which
one you will use

Poor choice of ap (hypothenar ap, stiffness, painful and

inadequate pulp reconstruction)

Savoir réparer ce que l’on pare - Raymond Vilain

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 THE PRINCIPLES
• Prepare the wound

• Choose the ap:

• Prefer local aps,

• Like to like (i.e. volar skin is

preferred to dorsal),

• Avoid hetero-digital aps,

microsurgical aps, too short aps
(Kutler, Atasoy,…)

• Calculate the migration of the ap you

need

• Draw the incisions And then …go ahead

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 CHOOSING THE FLAP
• Size,

• Availability,

• (expected) Sensibility,
Pulp length is 27 mm (index and
middle), 26 mm (annular) and 22
• Donor site morbidity, mm (little)
Pulp width is 15 mm
Pulp circonference is : (π x 15)/2 =
• One-stage surgery, 23,5 mm

• Early rehabilitation

Murai M, Lau H-K, Pereira BP, Pho RWH. A cadaver study on volume and surface area of the ngertip. J Hand Surg 1997; 22A: 935-941
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 CHOOSING THE FLAP
• Size

• Availability

• (expected) Sensibility,

• Donor site morbidity,

• One-stage surgery, index, palmar skin Auricular

In ≈ 10% of cases, the radial artery of the index

• Early rehabilitation or the ulnar artery of the auricular is lacking
 CHOOSING THE FLAP
• Size

• Availability

• (expected) Sensibility,

• Donor site morbidity,

• One-stage surgery,
Whatever the ap you will choose,
• Early rehabilitation expect a 2PD never less that 5-6 mm
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 CHOOSING THE FLAP
• Size

• Availability

• (expected) Sensibility,

• Donor site morbidity,

• One-stage surgery,

• Early rehabilitation
 CHOOSING THE FLAP
• Size Associated homodigital advancement ap + thenar ap

• Availability

• (expected) Sensibility,

• Donor site morbidity,

• One-stage surgery,

• Early rehabilitation
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SAME FINGER FLAP ?
Dorsal:
Joshi, Lim, Shen, Direct ow homodigital:
Iwasawa Venkataswami, Gilbert, Seegmuller,

Volar:
Bipedicled:
Hueston,
Elliot (TLA)
Souquet

Pulp: Reverse ow homodigital:

Atasoy, Kutler Lai, Brunelli
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 THE MOST IMPORTANT
• Do the simplest ap, the
one you are familiar with (if
indicated) and that you
know how to perform !

• A « gauze ap » allows you The reverse Atasoy’s ap !

to wait a few hours/days A not yet described but
totally useless ap
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 FLAPS MAY BE DIFFICULT TO PERFORM
inadequate debridement, too small
ap = Surgeon’s mistake !

• They are associated with a high number

of complications

• 118 pedicled aps: 79 antegrades, 10

retrogrades, 6 intermetacarpal, 5 kite
ap, 6 dorso-ulnar ...

• 42 complications in 42 cases (39%

smokers +++) with 10 partial
necroses, 13 epidermolysis, 4 venous
congestion, 4 super cial infection, 3
deep infection, 8 secondary healing
of ap edges,….mostly in antegrade
aps

Henry M. Speci c complications associated with different types of intrinsic pedicle aps of the hand. J Reconstr Microsurg.
2008;24(3):221-5.
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Tang JB et al. Repair and Reconstruction of Thumb and Finger Tip Injuries. A Global View. Clin Plastic Surg 2014; 41:325–359
 LONG FINGERS- MY PERSONAL CHOICES

• Very distal and dorsal oblique Atasoy

• Transverse and volar oblique

Elliot: TLA ap
(< 50%)

• Lateral or distal (< 50% of Island aps

the pulp)

• > 50% of the pulp Reverse

• Transverse, volar oblique,

limited size, index and middle Thenar ap
nger
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THUMB - MY PERSONAL CHOICES
• Vessels are shorter than at
the ngers - cannot be
dissected proximal to the
MP crease
Snow- Prefer Elliot’s variation
• Dorsal vascularisation is
independent from the volar
one

• Bi-pedicled volar aps are

preferred

Moberg- Prefer dissection at the MP crease

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 PULP + BONE + NAIL

• Replantation

• Toe transfer

• Reposition + ap

• Reposition

• Terminalisation
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 DISTAL REPLANTATION ARE
• Quite fast to perform (only
vessels repair)

• A single artery for zone I & II and

a + v repair for more proximal
injury

• Usually give excellent results, in

any case superior to any other
technique

• Success rate from 64% (Yamano,

1985) to 99% (Tamai, 1982).

Chen classification
 PARTIAL REPLANT MAY BE AN OPTION

• Surgical technique published by

Douglas (1959) then Mantero
(1975) updated by Foucher
(1992)

• « en bloc » reposition of the distal

phalanx AND the nail apparatus
(or only the nail apparatus-Elliott)

• And coverage of the pulp with a

ap
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 SIMPLE FRAGMENT REPOSITION ?
• Can give surprising results

• « Cap technique », Hirase’s technique

[Aluminium foil + cool water (+4°c) for 72 hours],…

• DP-I & DP-II 100% survival rate,

DP-III 50%

• < 25% success in zone IIB.

• Favourable Factors
• 0% of success after 5 hours… – Level (p=0.015)
– Sharp vs crush (p=0.004)
– Smoker (p=0.016)
– <4 hrs (p=0.016) 9 months old child,
reposition at 6 hours
Hirase Y: Salvage of ngertip amputated at nail level: new surgical principles and treatments. Ann. Plast. Surg. 1997 Feb; 38(2): 151-7
Adani R., Marcoccio I., Tarallo L. Treatment of ngertips amputation using the Hirase technique. Hand Surg. 2003 Dec; 8(2): 257-264
Elliott D, Moiemen NS. Composite graft replacement of digital tips 1. Before 1850 and after 1950. J Hand Surg 1997;22:341-5.
Moiemen NS, Elliot D. Composite graft replacement of digital tips 2. A study in children. J Hand Surg 1997;22:346-52.




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 TOE TRANSFER ?
• Very dif cult

• Can give excellent results

• Rarely done as an
emergency

• The only way to

reconstruct a near normal
ngertip if replantation was
not possible or successful
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 DO NOT FORGET THAT THE RESULTS ALSO
DEPEND OF THE PATIENT

• 82 pulp injuries

• Post-op DASH 35 (nl 10)

• DASH at one month 17

• Over half of the variations in the clinical results were

related to a depression or the mechanism of injury.
Depression was related to pain intensity, DASH score and
the length out of work
Bot AGJ, Bossen JKJ, Mudgal CS, Jupiter JB, Ring D. Determinants of Disability After Fingertip Injuries. Psychosomatics
2014:55:372–380
 CONCLUSION
• Repair all lesions i.e. pulp AND nail

• In case of doubt, the simplest treatment should be chosen

• Between aps, choose the simplest and/or the one that

allows for early mobilization. Most of surgical wounds can
be covered by well-described and known aps that you
should be able to use

• Replantation give the best results

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