By
Mustafa Z. Hasan
 injury
to the fingertip can result in
significant functional and aesthetic deficit.
 The fingertip is the most commonly injured
part of the hand, comprising 45% of hand
injuries presenting to emergency rooms.
 Males are injured more frequently than
females, especially in the workplace.
 The long finger is most often affected, the
thumb and 5th are the least commonly
involved.
 The
main principle of nailbed repair is
reapproximating the injured tissue to
anatomic position.
 The hallmark of injuries to the nailbed is the
subungual hematoma.
1- A hematoma involving less than 25% of the
visible surface of the nail;
 Managed with drainage of the hematoma as
necessary for pain relief.
2- A subungual hematoma that occupies more
than 25% of the visible surface of the nail;
 Failure of primary healing may result in
scarring of the matrix, with subsequent
deficiency in nail growth or adherence.
 The nail is carefully separated from the
underlying bed and eponychium
 and is set aside in sterile saline for later use.
 Debridement of the wound edges should be
kept to an absolute minimum.
Lacerations of the nailbed are repaired
under loup magnification using precise
interrupted suture technique. Fine (6-0 or 70) absorbable suture material on small
atraumatic cutting needles is recommended.
 if the space between the germinal matrix
and the eponychium is not maintained,
adhesion may occur, with subsequent
distortion of nail growth. The nail itself is
the most ideal dressing.

3- Treatment of avulsion injuries to the
nailbed;
 Segments of avulsed matrix are best replaced
as a graft.
 If the avulsed tissue is lost or too damaged ,
the defect can be managed with splitthickness grafts taken from an adjacent
uninjured portion of the nailbed.
 When larger segments of graft are needed, a
toe may be used as a donor site.
very effective for loss of skin up to 1 cm2,
particularly effective in tip amputations in small
children.
 Contraction of the wound usually results in a
small scar that typically is not overly sensitive.
 Larger wounds, result in a painful and
hypersensitive scar.
 If a small portion of distal phalanx is visible,
judicious shortening of the tip is allowable.
However, if more than half of the phalanx is
resected, the patient will develop a "hook nail"
deformity from loss of nailbed support.

 allows
quick coverage of wounds.
 in minor fingertip amputations, not involving
bone or nailbed.
 skin of the amputated part may be replaced.
 other donor sites (including the ulnar border
of the hand, the volar wrist crease, the
antecubital area, or other distant sites)
 Disadvantages; instability of the grafted skin,
poor tactile return, and hypersensitivity of
the fingertip; and because of that patient
neglects to use the finger.
 ideally
suited for transverse or slightly volar
amputations at the midnail level.
 Disadvantages ; include the limited mobility
of these flaps, and placement of a scar
directly on the fingertip.
 for
transverse midnail or dorsally directed
fingertip amputations.
 Occasionally postoperative hypesthesia,
hypersensitivity, or cold intolerance will
occur. Additionally, if a tight closure is used
over a shortened phalanx this repair is
particularly prone to induce a hook-nail
deformity.
 Although
this procedure has been described
for all digits of the hand, the Moberg flap is
best suited for transverse thumb tip
amputations.
 Use of a volar neurovascular advancement
flap for digits other than the thumb, may
lead to dorsal skin necrosis.
 Disadvantages ; joint contractures, tip
necrosis and painful scarring, seem to occur
more frequently when the Moberg or similar
flaps are used on digits other than the
thumb.
 best
choice for volar oblique tip
amputations. It can also be used for dorsally
oriented amputations in either a rotation
design or unfurled with deepithelialization of
the flap.
 Complications include donor-site depression,
skin graft hyperpigmentation, digital
stiffness, and cold intolerance.
 can
be used for amputations of any
orientation on the index, long, or ring
fingers.
 Age is not a contraindication to the use of
thenar flaps. Thenar flaps have been used
with equal success with patients from 1 to 76
years of age.
(a)the MCP joint of the recipient finger is fully
flexed in a protective position, minimizing PIP
joint flexion. Flexing of DIPjoint when present,
further improves the position of immobilization.
(b) the thumb is placed in full palmar abduction or
opposition.
(c) the thenar flap is designed with a proximally
based pedicle, high on the thenar eminence so
its lateral margin is at the MCP skin crease.
(d) the pedicle of the flap is severed after 10 to 14
days.
 Important
hemipulp areas where one might
wish to restore sensation are the thumb,
index, and the ulnar aspect of the 5th finger
 donor site is the ulnar ring finger, or long
finger.
 sensory loss is experienced in the donor
finger
 The neurovascular island flap is almost
always useful for restoring at least protective
sensation to an otherwise anesthetic digital
surface.
 Surely
technical precision in elevating the
flap plays some role, but other factors such
as lack of cortical reeducation or wound
healing problems may decrease the quality of
the result.
 microsurgery
has allowed other options in
the treatment of fingertip amputations, but
with technical difficulty of very distal
replantation.
 However, some authors have shown that an
acceptable survival rate.
 Delayed free-tissue transfer from the toes
also yields functional results, while restoring
physical appearance to nearly normal.
 When
flap coverage is needed but options
within the hand have been exhausted, the
groin flap or the radial forearm flap become
the workhorse choices.
 fascia-only radial forearm flap with a skin
graft to provide a less bulky and more
serviceable fingertip in a one-stage
procedure.