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Reconstruction of Fingertip Injuries: Surgical Tips and Avoiding Complications
SURGICAL TECHNIQUE
Reconstruction of Fingertip Injuries: Surgical Tips and Avoiding Complications Joao B. Panattoni, MD, Ignacio Roger De Ona, MD, Mohammed M. Ahmed, MD The fingertip is the most commonly injured part of the hand. When replantation of a fingertip amputation is not possible, flap reconstruction may be necessary for a functional and aesthetically pleasing outcome. This paper reviews commonly utilized reconstruction techniques with a focus on technical tricks and potential complications and how to avoid them, with illustrative cases. (J Hand Surg Am. 2015;-(-):-e-. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Key words Complication, fingertip, injury, reconstruction, surgical tip.
portion of the finger distal to the insertion of the flexor and extensor tendons, is the most commonly injured part of the hand.1,2 The unique anatomy and specialized structure of the fingertip make it critical for functions such as sensation, fine handling, and gripping. As such, it is important to be familiar with the treatment options available for such injuries in order to provide a good functional and aesthetic outcome for patients. Although replantation of an amputated fingertip may be the best way to achieve aesthetic and functional reconstruction, this is not always possible.3 Factors including mechanism of injury, preservation and condition of the amputated part, ischemia time, availability of a trained team at an institution, and adequacy of resources can substantially influence and even preclude the capability of performing a distal replantation. Fingertip flap reconstruction then becomes important. Several techniques have been described for fingertip reconstruction with good functional and cosmetic outcomes. Different factors must be considered when choosing one surgical technique over another. Most
T
HE FINGERTIP, DEFINED AS THE
From the Department of Orthopaedic Surgery, St. Louis University, Saint Louis, MO. Received for publication August 14, 2014; accepted in revised form February 18, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Joao B. Panattoni, MD, Department of Orthopaedic Surgery, St. Louis University, 3635 Vista Ave., 7th Floor, Desloge Towers, St. Louis, MO 63130; e-mail: [email protected]. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.02.010
important, the characteristics of the injury will dictate what type of reconstruction is available. Other factors that are evaluated can be divided into patient factors (hand dominance, occupation, age, expectations, previous injuries, smoking status, comorbidities), surgeon factors (previous experience, training, microsurgical skills), and institution factors (operating room availability, equipment and team availability). The purpose of this paper is to provide a review of specific reconstructive methods and to focus on surgical pearls, possible complications, and measures to avoid these complications. Table 1 outlines each of the techniques described in this paper. INDICATIONS AND CONTRAINDICATIONS Fingertip reconstruction is indicated for restoration of good padding of the finger that will allow for adequate grip function, restoration of sensation, and a good aesthetic result in the setting where replantation is not possible and shortening with revision amputation is not desirable. Although every effort should be made to provide recovery of sensation, this will vary and depends on several factors including the technique utilized, patient age, smoking status, and comorbidities. Depending upon the geometry, location, and mechanism of the injury, one technique may be preferred over another. Specific indications for particular techniques are discussed with each technique described. The surgical procedure can vary from simple to complex. The longer and more complex procedures will be preferred for patients of younger age and with
Ó 2015 ASSH
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Published by Elsevier, Inc. All rights reserved.
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FINGERTIP INJURY RECONSTRUCTION: TIPS TO AVOID COMPLICATIONS
TABLE 1.
Techniques, Indications, and Technical Tips to Avoid Complications
Technique
Indications/Contraindications
Technical Tips to Avoid Complications
Healing by secondary intention
< 1.0e1.5 cm2esized defect No exposed bone
Thoroughly initially clean and debride. Limit dressing changes to once a week. Limit manipulation during dressing changes.
V-Y flap
Dorsal oblique or transverse defects Apex of triangle should be at a DIP joint crease. Contraindicated in volar oblique defects Base of triangle should not be wider than the nail plate. < 1.0-cmesized defect Avoid tight sutures to prevent hook nail deformity. Use gentle traction with skin hook for flap tension during proximal dissection.
Thenar flap
Flap can be elevated distally or in an “H” pattern. Volar oblique defects for index and Thenar H flap can mitigate the need for skin graft middle finger for donor site and be closed primarily. Contraindicated in ring and little fingers Elevate flap as close to thumb metacarpophalangeal or any pathology that may predispose joint but remain superficial because neurovascular to joint stiffness structures are just deep to flap.
Cross-finger flap
Volar oblique defects for any or multiple digits Contraindications similar to thenar flap
Antegrade neurovascular Volar, transverse, or radial/ulnar island flap oblique defects Contraindicated on radial side of index and ulnar side of little digit owing to arterial dominance of digits
Use clear plane above paratenon of extensor tendon. Transverse incisions of flap should be at the PIP and DIP joints to ensure inclusion of artery supplying the flap. Longitudinal incision can be placed between palmar and dorsal glabrous skin to provide a larger flap width. Releasing Cleland ligament will provide increased separation of digits and improved comfort for patient. Avoid skeletonizing the neurovascular pedicle. Leaving fat pad around neurovascular bundle will preserve vena commitantes, allowing flap drainage. Early active and gentle passive range of motion will prevent scar formation and contractures.
Retrograde vascular island flap
Larger volar, transverse, or radial/ulnar oblique defects Contraindications similar to antegrade island flap
Zig-zag approach connecting donor and receptor area allows better exposure and less scar retraction. Avoid skeletonizing pedicle by leaving some fat pad attached. Ligating distal vessels with a suture instead of a ligaclip leaves less of a bump in the fat pad after healing. Early active and gentle passive range of motion.
Toe pulp transfer
Large defects involving full pulp loss Relatively contraindicated in older patients, smokers, or patients with previous vascular disease
Use a foot that will match on the site of injury. Use the digital artery of the foot to anastamose to the digital artery of finger whenever possible, although the dorsalis pedis artery can also be used. Best veins for receptor area are located at the metacarpophalangeal joint dorsally.
tissue constituting the finger pulp. Stability of the finger pulp results from fibrous septae that radiate from the periosteum of the distal phalanx to the skin, with fatty tissue within that scaffold network to provide padding. The fingertip has a rich vascular supply from the terminal branches of the digital arteries. The thumb, index, and middle fingers have a dominant ulnar digital artery; in the ring and little fingers, the dominant is the radial digital artery. The 2 digital arteries anastomose as transverse palmar arches in 3 consistent locations: at the level of the C1 (proximal transverse palmar arch) and C2 (middle transverse
no comorbidities. Indeed, when the amputated part is available and in good condition with short ischemia time and in a young patient, fingertip replantation of a distal injury may be favored over reconstruction of the amputation. SURGICAL ANATOMY A good understanding of fingertip anatomy is crucial to appropriate management. The skin and epidermis of the volar fingertip is thick with deep papillary ridges. Underneath this layer lies a highly vascular fibrofatty J Hand Surg Am.
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FIGURE 1: Atasoy V-Y flap. A Flap outline. B, C Flap is elevated and advanced. D Flap inset. E, F Final result.
FIGURE 2: Failed V-Y flap. Overaggressive proximal edge dissection during flap elevation resulted in failure.
FIGURE 3: Failed V-Y flap. Inadequate deep dissection and mobilization resulted in increased skin tension and incomplete bone coverage.
palmar arch) cruciate pulleys and just distal to the flexor digitorum profundus tendon insertion (distal transverse palmar arch).4 These arterial system arches form the anatomical basis for many of the techniques described, specifically the pedicle-based island flaps.
This technique is contraindicated in large defects with exposed bone. Although many different dressing strategies have been described, the basis for each involves granulation and wound contraction followed by re-epithelialization of soft tissue loss.2,5 The acute injury is debrided under local anesthesia. A sterile
Healing by secondary intention For simple defects measuring less than 1.0 to 1.5 cm2, and without exposed bone, healing by secondary intention has been described by Mennen and Wise.5 J Hand Surg Am.
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FIGURE 4: Cross-finger flap. A Flap outline. B Elevation of flap from adjacent digit. C Flap inset on injured fingertip. D Final result.
fingertip injuries or transverse amputations with sufficient remaining tissue proximally ( 1 cm defect).6 It is contraindicated in volar oblique injuries. When designing this flap, the apex of the triangle is placed at the level of the distal interphalangeal (DIP) joint crease. The base of the triangle (distally) is not wider than the nail plate. In order to keep the flap well perfused; the dorsal dissection proceeds on the periosteum proximally until the flexor tendon attachment is seen. This also helps facilitate flap advancement by dividing the anchoring periosteal septae. The proximal edge of the flap is very cautiously dissected with a light spreading action of the scissors and cutting only dermal septae to avoid injury to the terminal branching digital vessels. Looser suturing of the distal flap will provide a more rounded pulp contour. Tight sutures from the skin at the tip to the nail bed should be avoided, preferably allowing granulation to develop to allow for support of the distal nail plate and prevent hooking of the nail (Fig. 1). It is
occlusive or semiocclusive dressing is then applied. These dressings are usually changed once a week with limited manipulation and cleaning of the defect. As Mennen and Wise5 describe, the dressing acts to contain “wound fluid” that is stable in temperature, pH, and pro-inflammatory exudate conducive to healing.5 The total recovery time is variable between 4 and 6 weeks. Good to excellent clinical outcomes have been reported with this technique.2,5 Success is dependent on patient compliance and motivation. It is time consuming and may prevent early return to work and may result in a less aesthetic outcome than other reconstruction methods. Despite this, it is inexpensive and is frequently an effective method for treating small fingertip injuries without bone loss. Terminal pulp V-Y flap Also known as Atasoy flap, the terminal pulp V-Y flap is best indicated for dorsal oblique or transverse J Hand Surg Am.
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FIGURE 5: Cross-finger flap shows the supplying dorsal digital artery. The dorsal PIP and DIP creases must be included to ensure the artery is safely within the flap.
FIGURE 6: Failed cross-finger flap. Too-narrow design and toodistal flap elevation led to damage to the supplying artery and subsequent flap failure.
unnecessary to suture the proximal portion of the flap if this applies too much tension and simply allow this to heal secondarily. During the dissection, there is a risk of injury to the distal arch between the digital arteries (distal transverse digital arch) that is about 0.5 cm distal to the volar DIP joint crease.4 Flap release in this area has to be done very carefully, using the belly of the scalpel. Placing the flap under gentle traction with a skin hook during this more proximal deep release will place the anchoring septal fibers under tension in a way that only those will be cut by the scalpel, not the supplying artery (Fig. 2). Adequate and generous mobilization of the flap will prevent areas of tension and facilitate insetting. Inadequate proximal mobilization and dissection will not allow sufficient advancement to cover the wound, and excessive tension on flap closure may compromise perfusion (Fig. 3). Finally, the use of finger tourniquet, which is routine in these cases, should be discontinued after conclusion of the procedure. One way to ensure this is not accidentally left in place with potentially disastrous consequences is to place a hemostat on the tourniquet as a reminder. Occasional removal of a few sutures at this time may also be done if they seem excessively tight and cause flap blanching
the index and middle fingers and should be used judiciously in adults owing to the risk of flexion contracture of the finger.8 The flap can be elevated in multiple ways including distally based or in an “H” pattern.9 The elevation of the donor area with the use of an “H” design can facilitate closure upon flap division.10 It is important to avoid the use of a skin graft at the donor area, decreasing the risk of flexion contracture hypersensitivity on the scar and potential unaesthetic color mismatch. Elevation of the flap closer to the thumb metacarpophalangeal joint crease results in a better donor site because there is greater skin mobility allowing direct donor site wound closure and also necessitating less flexion on the recipient finger than the more proximal donor site that was originally described. However, care should be taken to avoid injury to the digital neurovascular bundles that are superficial in that area. The flap is typically divided 2 to 3 weeks after the initial flap elevation. Cross-finger flap The cross-finger flap, like the thenar flap, is indicated for volar oblique injuries. However, it is technically easier to perform with the additional advantage that it can be used in any digit or multiple digits by stacking the digits adjacent to each other for multiple injured fingertips. Also, it is a very reliable technique for larger defects. It was first described by Gurdin and Pangman11 and modified by Cronin.12 The flap is designed at the level of the middle phalanx dorsally,
Thenar flap Initially described by Gatewood7 and revised by Flatt,8 the thenar flap is more commonly indicated for volar oblique injuries. It is better recommended for J Hand Surg Am.
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FIGURE 7: Antegrade flow neurovascular island flap. A Radial oblique fingertip injury with both volar and dorsal soft tissue defect. B Antegrade flow neurovascular island flap after elevation and final inset immediately after surgery. C Two weeks following surgery.
because this will create a wider flap and prevent kinking of the flap when it is transposed and inset. Finally, we routinely release the Cleland ligament, which mobilizes the flap even further and increases the separation between the 2 fingers, thus yielding improved comfort. Like the thenar flap, this flap is usually divided 2 to 3 weeks after initial elevation. It is important to inform the patient about the difference in skin color and quality, especially for patients with darker skin tone at both the donor and the recipient sites (Fig. 4D).
going from the proximal interphalangeal (PIP) to the DIP creases. There is a very clear plane of dissection superficial to the paratenon of the extensor mechanism; keeping all the subcutaneous tissue attached to the skin of the flap but at the same time maintaining paratenon over the extensor mechanism for skin grafting (Fig. 4). Besides providing perfusion of the flap initially, this will also help with the functional outcome because it will provide good padding for the newly reconstructed pulp. The transverse incisions should be made at the PIP and DIP creases dorsally. This ensures that the supplying artery (dorsal branch of the proper digital artery) is included within the flap (Fig. 5). The arterial supply to the flap can be at risk if the flap is designed too narrow or placed under excessive tension (Fig. 6). During skin graft placement on the donor finger, this supplying artery is also at risk from accidental suture injury to the artery. Extend these transverse limbs all the way to the junction between the volar and the dorsal glabrous skin (both radially and ulnarly), J Hand Surg Am.
Antegrade flow neurovascular island flap The antegrade flow neurovascular island flap incorporates skin and subcutaneous tissue and advances an island on a single digital neurovascular pedicle to cover tissue defects at the tip of the same digit. This is a homodigital neurovascular island flap because it is innervated from the digital nerve and artery and inset on the same digit. As described by Varitimidis et al,13 it can be used for transverse amputations, or with any oblique pattern, and provides tissue of adequate bulk to the r
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FIGURE 8: Retrograde flow vascular island flap. A Large fingertip injury of the long finger with the anticipated flap outlined. B Flap elevation with pedicle shown. C Same patient after flap inset. D Final result.
fingertip. A step-advancement approach has also been described to interdigitate into the flexion creases.14 It is important to avoid skeletonizing the neurovascular bundle because there is no need to identify and isolate the nerve from the artery and, more important, it can injure the venous outflow of the pedicle. Also, by extending the base of the flap all the way to the PIP joint crease, more protection is afforded to the blood supply (Fig. 7). Leaving the fat pad around the bundle will contain the accompanying veins and keep them protected. Further, owing to the arterial dominance of the fingers, this flap should be avoided on the radial side of the index finger and ulnar side of the little finger. It is important to start with early active and gentle passive range of finger motion to minimize flexion contracture and finger stiffness.
this homodigital flap uses the neurovascular pedicle of the skin and soft tissue to cover a defect on the same digit. However, unlike the antegrade island flap, this flap uses the anastomosing transverse arch as its arterial inflow; it is transposed on this axis as a retrograde flow pedicle to reach the distal defect. By doing so, this flap can be used to cover bigger defects including complete amputations of the finger pulp. Dorsal or volar obliquity to the wound is inconsequential because this flap can cover either defect. The indications are similar to those of a crossfinger flap, with the advantage of being a 1-step procedure and having less color discrepancy than a cross-finger flap. This flap is, however, technically more demanding, with a chance of venous congestion in the postoperative period. Once the neurovascular bundle is located, the nerve should be dissected volarly, leaving some fat tissue with the venae commitantes connected to the digital artery (Fig. 8). The digital nerve, having been dissected away, is not divided. When ligating the digital artery proximally,
Retrograde flow neurovascular island flap Lai et al15 and Kojima et al16 are credited with describing this distally based digital artery flap. Similar to the previously described neurovascular island flap, J Hand Surg Am.
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FIGURE 9: Toe pulp transfer. A Anticipated toe pulp donor site and toe pulp with vascular pedicle. BeD Clinical photographs after flap inset and final result.
suture should be used instead of a metal clip, because the latter can protrude at the tip of the finger after the pulp has healed. Careful dissection should be performed with care to preserve the distal communications between the radial and the ulnar digital arteries at the level of the DIP joint. As with the antegrade island flap, this flap should be avoided on the radial side of the index finger and ulnar side of the little finger. Because there is a chance of venous congestion with this flap, it is especially important to avoid tight skin closure during flap insetting. We recommend starting with early active and gentle passive range of motion of the finger to reduce the risk of flexion contracture.
It is better to use the foot that will match the defect on the side of injury. For example, a defect on the radial side of the index finger will be better reconstructed with a toe pulp from the right foot. The dorsalis pedis artery can be anastomosed to the digital artery on the hand. However, it is always safer to prepare the digital artery from the foot as a backup (in case of a dominant plantar system). The digital nerve from the foot is coapted directly to the digital nerve of the hand. The best recipient veins are at the dorsum of the hand at the level of the metacarpophalangeal joints. The donor vein can be passed from volar to dorsal, proximal to the intermetacarpal ligament. Appropriate patient selection is important, preferentially, for younger patients who are nonsmokers and are free of vascular disease. Close monitoring of flap circulation is important in the immediate postoperative period.
Toe pulp transfer Initially described by Buncke and Rose,17 this reconstruction allows for transfer of tissue that is most similar in structure to the native fingertip pulp. Its main advantages are the possibility of covering large defects and good recovery of sensation.17 Disadvantages of this procedure include donor site defects, long operative time, and technical difficulty. However, with proper patient and injury selection, this is the flap that will most closely replace similar tissue and it has high patient satisfaction with good functional outcome (Fig. 9).18 J Hand Surg Am.
Complications The most common complications of fingertip reconstruction include hypersensitive scar with persistent pain, nail deformity (hook nail, ridges, split nail), diminished sensation, cold intolerance, scar retraction, flexion contractures, chronic ulceration, infection, and flap loss. As already described, there may be complications specific to the flap used but there are measures r
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7. Gatewood MD. A plastic repair of finger defects without hospitalization. JAMA. 1926;87(18):1479. 8. Flatt AE. The thenar flap. J Bone Joint Surg Br. 1957;39(1):80e85. 9. Melone CP Jr, Beasley RW, Carstens JH Jr. The thenar flap—an analysis of its use in 150 cases. J Hand Surg Am. 1982;7(3): 291e297. 10. Smith RJ, Albin R. Thenar “H-flap” for fingertip injuries. J Trauma. 1976;16(10):778e781. 11. Gurdin M, Pangman WJ. The repair of surface defects of fingers by trans-digital flaps. Plas Reconstr Surg. 1950;5(4):368e371. 12. Cronin TD. The cross finger flap: a new method of repair. Am Surg. 1951;17(5):419e425. 13. Varitimidis SE, Dailiana ZH, Zibis AH, Hantes M, Bargiotas K, Malizos KN. Restoration of function and sensitivity utilizing a homodigital neurovascular island flap after amputation injuries of the fingertip. J Hand Surg Br. 2005;30(4):338e342. 14. Hammouda AA, El-Khatib HA, Al-Hetmi T. Extended stepadvancement flap for avulsed amputated fingertip—a new technique to preserve finger length: a case series. J Hand Surg Am. 2011;36(1):129e134. 15. Lai CS, Lin SD, Yang CC. The reverse digital artery flap for fingertip reconstruction. Ann Plast Surg. 1989;22(6):495e500. 16. Kojima T, Tsuchida Y, Hirasé Y, Endo T. Reverse vascular pedicle digital island flap. Br J Plast Surg. 1990;43(3):290e295. 17. Buncke HJ, Rose EH. Free toe-to-fingertip neurovascular flaps. Plast Reconstr Surg. 1979;63(5):607e612. 18. Lin CH, Lin YT, Sassu P, Lin CH, Wei FC. Functional assessment of the reconstructed fingertips after free toe pulp transfer. Plast Reconstr Surg. 2007;120(5):1315e1321.
to diminish these risks. The more complex reconstructions may be more prone to problems. The most important factor to prevent failure is to have the proper indications. Thorough discussion with the patient regarding complications, postoperative management/ therapy, and realistic expectations should be undertaken in order to yield better patient satisfaction. REFERENCES 1. Sorock GS, Lombardi DA, Hauser RB, Eisen EA, Herrick RF, Mittleman MA. Acute traumatic occupational hand injuries: type, location and severity. J Occup Environ Med. 2002;44(4):345e351. 2. Lemmon JA, Janis JE, Rohrich RJ. Soft-tissue injuries of the fingertip: methods of evaluation and treatment. An algorithmic approach. Plast Reconstr Surg. 2008;122(3):105e117. 3. Scheker LR, Becker GW. Distal finger replantation. J Hand Surg Am. 2011;36(3):521e528. 4. Strauch B, de Moura W. Arterial system of the fingers. J Hand Surg Am. 1990;15(1):148e154. 5. Mennen U, Wise A. Fingertip injuries management with semiocclusive dressing. J Hand Surg Br. 1993;18(4):416e422. 6. Atasoy E, Loakimidis E, Kasdan ML, Kutz JE, Kleinert HE. Reconstruction of the amputated fingertip with a triangular volar flap. A new surgical procedure. J Bone Joint Surg Am. 1970;52(5): 921e926.
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Reconstruction of Fingertip Injuries: Surgical Tips and Avoiding Complications Joao B. Panattoni, MD, Ignacio Roger De Ona, MD, Mohammed M. Ahmed, MD The fingertip is the most commonly injured part of the hand. When replantation of a fingertip amputation is not possible, flap reconstruction may be necessary for a functional and aesthetically pleasing outcome. This paper reviews commonly utilized reconstruction techniques with a focus on technical tricks and potential complications and how to avoid them, with illustrative cases. (J Hand Surg Am. 2015;-(-):-e-. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Key words Complication, fingertip, injury, reconstruction, surgical tip.
portion of the finger distal to the insertion of the flexor and extensor tendons, is the most commonly injured part of the hand.1,2 The unique anatomy and specialized structure of the fingertip make it critical for functions such as sensation, fine handling, and gripping. As such, it is important to be familiar with the treatment options available for such injuries in order to provide a good functional and aesthetic outcome for patients. Although replantation of an amputated fingertip may be the best way to achieve aesthetic and functional reconstruction, this is not always possible.3 Factors including mechanism of injury, preservation and condition of the amputated part, ischemia time, availability of a trained team at an institution, and adequacy of resources can substantially influence and even preclude the capability of performing a distal replantation. Fingertip flap reconstruction then becomes important. Several techniques have been described for fingertip reconstruction with good functional and cosmetic outcomes. Different factors must be considered when choosing one surgical technique over another. Most
T
HE FINGERTIP, DEFINED AS THE
From the Department of Orthopaedic Surgery, St. Louis University, Saint Louis, MO. Received for publication August 14, 2014; accepted in revised form February 18, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Joao B. Panattoni, MD, Department of Orthopaedic Surgery, St. Louis University, 3635 Vista Ave., 7th Floor, Desloge Towers, St. Louis, MO 63130; e-mail: [email protected]. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.02.010
important, the characteristics of the injury will dictate what type of reconstruction is available. Other factors that are evaluated can be divided into patient factors (hand dominance, occupation, age, expectations, previous injuries, smoking status, comorbidities), surgeon factors (previous experience, training, microsurgical skills), and institution factors (operating room availability, equipment and team availability). The purpose of this paper is to provide a review of specific reconstructive methods and to focus on surgical pearls, possible complications, and measures to avoid these complications. Table 1 outlines each of the techniques described in this paper. INDICATIONS AND CONTRAINDICATIONS Fingertip reconstruction is indicated for restoration of good padding of the finger that will allow for adequate grip function, restoration of sensation, and a good aesthetic result in the setting where replantation is not possible and shortening with revision amputation is not desirable. Although every effort should be made to provide recovery of sensation, this will vary and depends on several factors including the technique utilized, patient age, smoking status, and comorbidities. Depending upon the geometry, location, and mechanism of the injury, one technique may be preferred over another. Specific indications for particular techniques are discussed with each technique described. The surgical procedure can vary from simple to complex. The longer and more complex procedures will be preferred for patients of younger age and with
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
FINGERTIP INJURY RECONSTRUCTION: TIPS TO AVOID COMPLICATIONS
TABLE 1.
Techniques, Indications, and Technical Tips to Avoid Complications
Technique
Indications/Contraindications
Technical Tips to Avoid Complications
Healing by secondary intention
< 1.0e1.5 cm2esized defect No exposed bone
Thoroughly initially clean and debride. Limit dressing changes to once a week. Limit manipulation during dressing changes.
V-Y flap
Dorsal oblique or transverse defects Apex of triangle should be at a DIP joint crease. Contraindicated in volar oblique defects Base of triangle should not be wider than the nail plate. < 1.0-cmesized defect Avoid tight sutures to prevent hook nail deformity. Use gentle traction with skin hook for flap tension during proximal dissection.
Thenar flap
Flap can be elevated distally or in an “H” pattern. Volar oblique defects for index and Thenar H flap can mitigate the need for skin graft middle finger for donor site and be closed primarily. Contraindicated in ring and little fingers Elevate flap as close to thumb metacarpophalangeal or any pathology that may predispose joint but remain superficial because neurovascular to joint stiffness structures are just deep to flap.
Cross-finger flap
Volar oblique defects for any or multiple digits Contraindications similar to thenar flap
Antegrade neurovascular Volar, transverse, or radial/ulnar island flap oblique defects Contraindicated on radial side of index and ulnar side of little digit owing to arterial dominance of digits
Use clear plane above paratenon of extensor tendon. Transverse incisions of flap should be at the PIP and DIP joints to ensure inclusion of artery supplying the flap. Longitudinal incision can be placed between palmar and dorsal glabrous skin to provide a larger flap width. Releasing Cleland ligament will provide increased separation of digits and improved comfort for patient. Avoid skeletonizing the neurovascular pedicle. Leaving fat pad around neurovascular bundle will preserve vena commitantes, allowing flap drainage. Early active and gentle passive range of motion will prevent scar formation and contractures.
Retrograde vascular island flap
Larger volar, transverse, or radial/ulnar oblique defects Contraindications similar to antegrade island flap
Zig-zag approach connecting donor and receptor area allows better exposure and less scar retraction. Avoid skeletonizing pedicle by leaving some fat pad attached. Ligating distal vessels with a suture instead of a ligaclip leaves less of a bump in the fat pad after healing. Early active and gentle passive range of motion.
Toe pulp transfer
Large defects involving full pulp loss Relatively contraindicated in older patients, smokers, or patients with previous vascular disease
Use a foot that will match on the site of injury. Use the digital artery of the foot to anastamose to the digital artery of finger whenever possible, although the dorsalis pedis artery can also be used. Best veins for receptor area are located at the metacarpophalangeal joint dorsally.
tissue constituting the finger pulp. Stability of the finger pulp results from fibrous septae that radiate from the periosteum of the distal phalanx to the skin, with fatty tissue within that scaffold network to provide padding. The fingertip has a rich vascular supply from the terminal branches of the digital arteries. The thumb, index, and middle fingers have a dominant ulnar digital artery; in the ring and little fingers, the dominant is the radial digital artery. The 2 digital arteries anastomose as transverse palmar arches in 3 consistent locations: at the level of the C1 (proximal transverse palmar arch) and C2 (middle transverse
no comorbidities. Indeed, when the amputated part is available and in good condition with short ischemia time and in a young patient, fingertip replantation of a distal injury may be favored over reconstruction of the amputation. SURGICAL ANATOMY A good understanding of fingertip anatomy is crucial to appropriate management. The skin and epidermis of the volar fingertip is thick with deep papillary ridges. Underneath this layer lies a highly vascular fibrofatty J Hand Surg Am.
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FIGURE 1: Atasoy V-Y flap. A Flap outline. B, C Flap is elevated and advanced. D Flap inset. E, F Final result.
FIGURE 2: Failed V-Y flap. Overaggressive proximal edge dissection during flap elevation resulted in failure.
FIGURE 3: Failed V-Y flap. Inadequate deep dissection and mobilization resulted in increased skin tension and incomplete bone coverage.
palmar arch) cruciate pulleys and just distal to the flexor digitorum profundus tendon insertion (distal transverse palmar arch).4 These arterial system arches form the anatomical basis for many of the techniques described, specifically the pedicle-based island flaps.
This technique is contraindicated in large defects with exposed bone. Although many different dressing strategies have been described, the basis for each involves granulation and wound contraction followed by re-epithelialization of soft tissue loss.2,5 The acute injury is debrided under local anesthesia. A sterile
Healing by secondary intention For simple defects measuring less than 1.0 to 1.5 cm2, and without exposed bone, healing by secondary intention has been described by Mennen and Wise.5 J Hand Surg Am.
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FIGURE 4: Cross-finger flap. A Flap outline. B Elevation of flap from adjacent digit. C Flap inset on injured fingertip. D Final result.
fingertip injuries or transverse amputations with sufficient remaining tissue proximally ( 1 cm defect).6 It is contraindicated in volar oblique injuries. When designing this flap, the apex of the triangle is placed at the level of the distal interphalangeal (DIP) joint crease. The base of the triangle (distally) is not wider than the nail plate. In order to keep the flap well perfused; the dorsal dissection proceeds on the periosteum proximally until the flexor tendon attachment is seen. This also helps facilitate flap advancement by dividing the anchoring periosteal septae. The proximal edge of the flap is very cautiously dissected with a light spreading action of the scissors and cutting only dermal septae to avoid injury to the terminal branching digital vessels. Looser suturing of the distal flap will provide a more rounded pulp contour. Tight sutures from the skin at the tip to the nail bed should be avoided, preferably allowing granulation to develop to allow for support of the distal nail plate and prevent hooking of the nail (Fig. 1). It is
occlusive or semiocclusive dressing is then applied. These dressings are usually changed once a week with limited manipulation and cleaning of the defect. As Mennen and Wise5 describe, the dressing acts to contain “wound fluid” that is stable in temperature, pH, and pro-inflammatory exudate conducive to healing.5 The total recovery time is variable between 4 and 6 weeks. Good to excellent clinical outcomes have been reported with this technique.2,5 Success is dependent on patient compliance and motivation. It is time consuming and may prevent early return to work and may result in a less aesthetic outcome than other reconstruction methods. Despite this, it is inexpensive and is frequently an effective method for treating small fingertip injuries without bone loss. Terminal pulp V-Y flap Also known as Atasoy flap, the terminal pulp V-Y flap is best indicated for dorsal oblique or transverse J Hand Surg Am.
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FIGURE 5: Cross-finger flap shows the supplying dorsal digital artery. The dorsal PIP and DIP creases must be included to ensure the artery is safely within the flap.
FIGURE 6: Failed cross-finger flap. Too-narrow design and toodistal flap elevation led to damage to the supplying artery and subsequent flap failure.
unnecessary to suture the proximal portion of the flap if this applies too much tension and simply allow this to heal secondarily. During the dissection, there is a risk of injury to the distal arch between the digital arteries (distal transverse digital arch) that is about 0.5 cm distal to the volar DIP joint crease.4 Flap release in this area has to be done very carefully, using the belly of the scalpel. Placing the flap under gentle traction with a skin hook during this more proximal deep release will place the anchoring septal fibers under tension in a way that only those will be cut by the scalpel, not the supplying artery (Fig. 2). Adequate and generous mobilization of the flap will prevent areas of tension and facilitate insetting. Inadequate proximal mobilization and dissection will not allow sufficient advancement to cover the wound, and excessive tension on flap closure may compromise perfusion (Fig. 3). Finally, the use of finger tourniquet, which is routine in these cases, should be discontinued after conclusion of the procedure. One way to ensure this is not accidentally left in place with potentially disastrous consequences is to place a hemostat on the tourniquet as a reminder. Occasional removal of a few sutures at this time may also be done if they seem excessively tight and cause flap blanching
the index and middle fingers and should be used judiciously in adults owing to the risk of flexion contracture of the finger.8 The flap can be elevated in multiple ways including distally based or in an “H” pattern.9 The elevation of the donor area with the use of an “H” design can facilitate closure upon flap division.10 It is important to avoid the use of a skin graft at the donor area, decreasing the risk of flexion contracture hypersensitivity on the scar and potential unaesthetic color mismatch. Elevation of the flap closer to the thumb metacarpophalangeal joint crease results in a better donor site because there is greater skin mobility allowing direct donor site wound closure and also necessitating less flexion on the recipient finger than the more proximal donor site that was originally described. However, care should be taken to avoid injury to the digital neurovascular bundles that are superficial in that area. The flap is typically divided 2 to 3 weeks after the initial flap elevation. Cross-finger flap The cross-finger flap, like the thenar flap, is indicated for volar oblique injuries. However, it is technically easier to perform with the additional advantage that it can be used in any digit or multiple digits by stacking the digits adjacent to each other for multiple injured fingertips. Also, it is a very reliable technique for larger defects. It was first described by Gurdin and Pangman11 and modified by Cronin.12 The flap is designed at the level of the middle phalanx dorsally,
Thenar flap Initially described by Gatewood7 and revised by Flatt,8 the thenar flap is more commonly indicated for volar oblique injuries. It is better recommended for J Hand Surg Am.
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FIGURE 7: Antegrade flow neurovascular island flap. A Radial oblique fingertip injury with both volar and dorsal soft tissue defect. B Antegrade flow neurovascular island flap after elevation and final inset immediately after surgery. C Two weeks following surgery.
because this will create a wider flap and prevent kinking of the flap when it is transposed and inset. Finally, we routinely release the Cleland ligament, which mobilizes the flap even further and increases the separation between the 2 fingers, thus yielding improved comfort. Like the thenar flap, this flap is usually divided 2 to 3 weeks after initial elevation. It is important to inform the patient about the difference in skin color and quality, especially for patients with darker skin tone at both the donor and the recipient sites (Fig. 4D).
going from the proximal interphalangeal (PIP) to the DIP creases. There is a very clear plane of dissection superficial to the paratenon of the extensor mechanism; keeping all the subcutaneous tissue attached to the skin of the flap but at the same time maintaining paratenon over the extensor mechanism for skin grafting (Fig. 4). Besides providing perfusion of the flap initially, this will also help with the functional outcome because it will provide good padding for the newly reconstructed pulp. The transverse incisions should be made at the PIP and DIP creases dorsally. This ensures that the supplying artery (dorsal branch of the proper digital artery) is included within the flap (Fig. 5). The arterial supply to the flap can be at risk if the flap is designed too narrow or placed under excessive tension (Fig. 6). During skin graft placement on the donor finger, this supplying artery is also at risk from accidental suture injury to the artery. Extend these transverse limbs all the way to the junction between the volar and the dorsal glabrous skin (both radially and ulnarly), J Hand Surg Am.
Antegrade flow neurovascular island flap The antegrade flow neurovascular island flap incorporates skin and subcutaneous tissue and advances an island on a single digital neurovascular pedicle to cover tissue defects at the tip of the same digit. This is a homodigital neurovascular island flap because it is innervated from the digital nerve and artery and inset on the same digit. As described by Varitimidis et al,13 it can be used for transverse amputations, or with any oblique pattern, and provides tissue of adequate bulk to the r
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FIGURE 8: Retrograde flow vascular island flap. A Large fingertip injury of the long finger with the anticipated flap outlined. B Flap elevation with pedicle shown. C Same patient after flap inset. D Final result.
fingertip. A step-advancement approach has also been described to interdigitate into the flexion creases.14 It is important to avoid skeletonizing the neurovascular bundle because there is no need to identify and isolate the nerve from the artery and, more important, it can injure the venous outflow of the pedicle. Also, by extending the base of the flap all the way to the PIP joint crease, more protection is afforded to the blood supply (Fig. 7). Leaving the fat pad around the bundle will contain the accompanying veins and keep them protected. Further, owing to the arterial dominance of the fingers, this flap should be avoided on the radial side of the index finger and ulnar side of the little finger. It is important to start with early active and gentle passive range of finger motion to minimize flexion contracture and finger stiffness.
this homodigital flap uses the neurovascular pedicle of the skin and soft tissue to cover a defect on the same digit. However, unlike the antegrade island flap, this flap uses the anastomosing transverse arch as its arterial inflow; it is transposed on this axis as a retrograde flow pedicle to reach the distal defect. By doing so, this flap can be used to cover bigger defects including complete amputations of the finger pulp. Dorsal or volar obliquity to the wound is inconsequential because this flap can cover either defect. The indications are similar to those of a crossfinger flap, with the advantage of being a 1-step procedure and having less color discrepancy than a cross-finger flap. This flap is, however, technically more demanding, with a chance of venous congestion in the postoperative period. Once the neurovascular bundle is located, the nerve should be dissected volarly, leaving some fat tissue with the venae commitantes connected to the digital artery (Fig. 8). The digital nerve, having been dissected away, is not divided. When ligating the digital artery proximally,
Retrograde flow neurovascular island flap Lai et al15 and Kojima et al16 are credited with describing this distally based digital artery flap. Similar to the previously described neurovascular island flap, J Hand Surg Am.
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FIGURE 9: Toe pulp transfer. A Anticipated toe pulp donor site and toe pulp with vascular pedicle. BeD Clinical photographs after flap inset and final result.
suture should be used instead of a metal clip, because the latter can protrude at the tip of the finger after the pulp has healed. Careful dissection should be performed with care to preserve the distal communications between the radial and the ulnar digital arteries at the level of the DIP joint. As with the antegrade island flap, this flap should be avoided on the radial side of the index finger and ulnar side of the little finger. Because there is a chance of venous congestion with this flap, it is especially important to avoid tight skin closure during flap insetting. We recommend starting with early active and gentle passive range of motion of the finger to reduce the risk of flexion contracture.
It is better to use the foot that will match the defect on the side of injury. For example, a defect on the radial side of the index finger will be better reconstructed with a toe pulp from the right foot. The dorsalis pedis artery can be anastomosed to the digital artery on the hand. However, it is always safer to prepare the digital artery from the foot as a backup (in case of a dominant plantar system). The digital nerve from the foot is coapted directly to the digital nerve of the hand. The best recipient veins are at the dorsum of the hand at the level of the metacarpophalangeal joints. The donor vein can be passed from volar to dorsal, proximal to the intermetacarpal ligament. Appropriate patient selection is important, preferentially, for younger patients who are nonsmokers and are free of vascular disease. Close monitoring of flap circulation is important in the immediate postoperative period.
Toe pulp transfer Initially described by Buncke and Rose,17 this reconstruction allows for transfer of tissue that is most similar in structure to the native fingertip pulp. Its main advantages are the possibility of covering large defects and good recovery of sensation.17 Disadvantages of this procedure include donor site defects, long operative time, and technical difficulty. However, with proper patient and injury selection, this is the flap that will most closely replace similar tissue and it has high patient satisfaction with good functional outcome (Fig. 9).18 J Hand Surg Am.
Complications The most common complications of fingertip reconstruction include hypersensitive scar with persistent pain, nail deformity (hook nail, ridges, split nail), diminished sensation, cold intolerance, scar retraction, flexion contractures, chronic ulceration, infection, and flap loss. As already described, there may be complications specific to the flap used but there are measures r
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7. Gatewood MD. A plastic repair of finger defects without hospitalization. JAMA. 1926;87(18):1479. 8. Flatt AE. The thenar flap. J Bone Joint Surg Br. 1957;39(1):80e85. 9. Melone CP Jr, Beasley RW, Carstens JH Jr. The thenar flap—an analysis of its use in 150 cases. J Hand Surg Am. 1982;7(3): 291e297. 10. Smith RJ, Albin R. Thenar “H-flap” for fingertip injuries. J Trauma. 1976;16(10):778e781. 11. Gurdin M, Pangman WJ. The repair of surface defects of fingers by trans-digital flaps. Plas Reconstr Surg. 1950;5(4):368e371. 12. Cronin TD. The cross finger flap: a new method of repair. Am Surg. 1951;17(5):419e425. 13. Varitimidis SE, Dailiana ZH, Zibis AH, Hantes M, Bargiotas K, Malizos KN. Restoration of function and sensitivity utilizing a homodigital neurovascular island flap after amputation injuries of the fingertip. J Hand Surg Br. 2005;30(4):338e342. 14. Hammouda AA, El-Khatib HA, Al-Hetmi T. Extended stepadvancement flap for avulsed amputated fingertip—a new technique to preserve finger length: a case series. J Hand Surg Am. 2011;36(1):129e134. 15. Lai CS, Lin SD, Yang CC. The reverse digital artery flap for fingertip reconstruction. Ann Plast Surg. 1989;22(6):495e500. 16. Kojima T, Tsuchida Y, Hirasé Y, Endo T. Reverse vascular pedicle digital island flap. Br J Plast Surg. 1990;43(3):290e295. 17. Buncke HJ, Rose EH. Free toe-to-fingertip neurovascular flaps. Plast Reconstr Surg. 1979;63(5):607e612. 18. Lin CH, Lin YT, Sassu P, Lin CH, Wei FC. Functional assessment of the reconstructed fingertips after free toe pulp transfer. Plast Reconstr Surg. 2007;120(5):1315e1321.
to diminish these risks. The more complex reconstructions may be more prone to problems. The most important factor to prevent failure is to have the proper indications. Thorough discussion with the patient regarding complications, postoperative management/ therapy, and realistic expectations should be undertaken in order to yield better patient satisfaction. REFERENCES 1. Sorock GS, Lombardi DA, Hauser RB, Eisen EA, Herrick RF, Mittleman MA. Acute traumatic occupational hand injuries: type, location and severity. J Occup Environ Med. 2002;44(4):345e351. 2. Lemmon JA, Janis JE, Rohrich RJ. Soft-tissue injuries of the fingertip: methods of evaluation and treatment. An algorithmic approach. Plast Reconstr Surg. 2008;122(3):105e117. 3. Scheker LR, Becker GW. Distal finger replantation. J Hand Surg Am. 2011;36(3):521e528. 4. Strauch B, de Moura W. Arterial system of the fingers. J Hand Surg Am. 1990;15(1):148e154. 5. Mennen U, Wise A. Fingertip injuries management with semiocclusive dressing. J Hand Surg Br. 1993;18(4):416e422. 6. Atasoy E, Loakimidis E, Kasdan ML, Kutz JE, Kleinert HE. Reconstruction of the amputated fingertip with a triangular volar flap. A new surgical procedure. J Bone Joint Surg Am. 1970;52(5): 921e926.
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