- Email: [email protected]
Finger tip injuries
Finger Tip lnjuries--R. H. C. Robins FINGER
TIP
INJURIES
R. H. C. ROBINS, Truro Not many years ago hand sepsis was the Cinderella of surgery and it was to deal with the large numbers of cases involved that special hand clinics were started in this country. Preventive measures, anti-biotics and more enlightened surgery have combined to reduce their frequency and to mitigate their seriousness. In contrast, the incidence of minor injuries of the hand has not diminished. It is probably true that major hand injuries command skilled attention anywhere, but minor ones often receive less than their due. High in this category comes trauma to the finger tips which in its various forms is likely to outnumber all other types of case. The difference between success and failure will not be evident by gross mutilation or deformity, but by lengthened disability period, by needless loss of function in a digit and occasionally by disabling pain. IMPORTANCE OF SENSIBILITY
I would remind you of the emphasis laid by Moberg (1958) on the function of the finger tip as an organ of sensibility, the third eye as he called it, and of investigation. If there is one message which I would convey to you it is this: as in life, it is quality that counts. There are many considerations in the treatment of cru,shed and amputated finger tips, including the preservation of maximum length, but if there is no feeling in the normal tactile area, if there is no cushioning of the soft tissue, if there is a tender scar or neuroma, that digit tends to get passed over and excluded from the regular use of the hand. Treatment therefore must aim to provide a finger tip which is free from pain and surfaced with robust skin, at least part of which has good sensibility. Sometimes this will involve sacrificing some length, a situation rarely disastrou,s if only one digit is involved. CAUSES OF FAILURE
Let us start by looking at a few causes of failure. Misplaced Optimism
An amputated part of a digit which consists of rather more than the tip i:~ unlikely to survive after being sewn back without the benefit of microvascular surgery. The first step in preservation is to determine the viability of the parts, a clinical judgment that should not be too difficult provided that the physical signs are not clouded by the use of a tourniquet. The second point is that delayed su.rgery is more difficult than primary repair, clean healing harder to achieve, while the ultimate loss of tissue may be greater. Equally an attempt to preserve tissue of doubtful viability, even if attached by a narrow strip of skin is unlikely to succeed. This type of flap might survive if thinned to the level of a full thickness graft. It is usually preferable to replace all or part of such a flap with a free graft. Expectant Treatment
Disappointment at the results of sewing back an amputated finger tip may lead to a trial of allowing nature to take its course. After remaining unhealed for weeks, secondary stiffness will develop, and reduce the chances of benefit from flap repair, which might have been successful in the first place. Vol. 2
No. 2 1970
119
Finger Tip lnjuries--R. H. C. Robins Poorly Fashioned Stump
A poorly fashioned end to the finger with adherent scar, deformed nail and atrophy of the pulp may be a cause of pain varying from hypersensitivity to touch to the severity of an amputation neuroma. Most of these cases which finish in prolonged litigation began with inadequate primary treatment. PRIMARY TREATMENT
How then is the primary treatment to be decided? I propose to devote the space allotted for this su~bject to two types of injury: compound fractures of the distal phalanx without gross loss of tissue, and terminal amputations. Compound Fractures
Compound fractures are generally caused by crushing of the finger tip, so that laceration and contusion of the pulp accompany the fracture, which may be cornminuted. The nail may be dislocated and the matrix torn. Surgery consists of debridement and closure of the wound making best use of the viable skin available. A few details need emphasis. Swelling is inevitable and post-operative gauze dressings must never be applied circumferentially. A dislocated nail should not be removed if it can be replaced and used as a splint for the fractured terminal phalanx. When the nail has been avulsed and the matrix lacerated, the raw area should be re-surfaced with a split skin graft. Haematoma under an intact nail should be released by trephining a hole. Small fragments of fractured phalanx may be removed, but the distal pulp mu.st not be left unsupported, a situation more likely to arise in the thumb than the fingers. Where children are concerned the powers of recovery are great and conservative treatment should be followed. In the more serious injuries, consideration must be given to formal amputation through the base of the terminal phalanx. The best interests of the patient, particularly an older manual worker, will not be served by the preservation of tissue of low vitality, especially if the nail fold is torn and one can predict that regrowth of the nail will result in deformity and dysfunction. At this point crush inju.ries cat, sing compound fractures merge with complete or partial terminal amputations and where the tissue loss is predominantly on the dorsum of the digit, a formal amputa-
Fig. 1 Amputation through the terminal segment of the ring finger. The digit is shown in full flexion. The scar is away from the important tactile area. 120
Fig. 2 A poorly shaped bulbous finger.
Vol. 2
No. 2 1970
Finger Tip ln}uries--R. H. C. Robins
Fig. 3 A split skin graft (left) compares favourably with a full thickness graft (right).
Fig. 4 Vol. 2
No. 2
1970
Two fingers treated by full thickness grafts. 121
Finger Tip lnjuries--R. H. C. Robins
tion is usually the treatment of choice. Closure of the wound is effected with a volar skin flap, so that the normal tactile skin of the digit covers the end of the stump. Careful removal of the nail fold is necessary or else small horns of nail will re-appear and another operation will be needed to eradicate them. Note here the difference between a well-shaped stump (Fig. 1) and a bulbous end with nail remnants (Fig. 2).
Amputations The primary treatment of amputations consists of the maintenance of as much length as is compatible with good skin cover. The choice of method will be decided by the age and occupation of the patient, the level and direction of amputation, the ratio of "cut to crush" caused by the injury and the tidiness or otherwise of the wound. The alternatives are closure by local flaps, application of free grafts, a combination of the two or the use of flaps from elsewhere in the hand or from a distance. In all instances the preliminary treatment is the same---debridement of the wound and reduction of any projecting bone to just below the level of the soft tissue. If a volar flap is used, some shortening of the digit is likely to be required and this may be unacceptable to the patient. There are other means available. V sections may be excised from the lateral margins of the skin to effect a fish-mouth closure. This has the disadvantage of a terminal scar, but the method is suitable when protection will later be afforded by growth of the nail. A re-appraisal has recently been made by Fisher (1967) of a method described by Kutler (1947) in which triangular flaps are developed on either side of the finger, the apex being directed proximally and the base along the line of the amputation. These flaps are mobilised to cover the top of the finger and the fish-mouth defects on either side are closed by linear suture. Free skin grafts provide the most generally applicable method of treatment for terminal amputations. When the defect is little more than skin deep, a split skin graft is quite adequate. The tiresome habit of contracting exhibited by this type of graft is an advantage in this situation. Over a period of months the surrounding normal skin is drawn distally so that the final area covered by graft is smaller than the original defect. The appearance of this finger tip compares favourably with this one for which the more usual full thickness graft has been used the injury being
Fig. 5 Multiple injuries treated by suture, supplemented by grafts to preserve all possible length. 122
Vol. 2
No. 2
1970
Finger Tip ln'luries--R. H. C. Robins
neither fresh, clean nor neatly incised and therefore unsuited to more elaborate surgery. Full thickness grafts must be trimmed of all subcutaneous fat and smured into position. It is difficult to divest oneself of previously published work. In 1954 I reported the results of a series of post-auricular skin grafts. I would like to take this opportunity of saying that I think this unnecessary and that the forearm provides a more appropriate donor area. If skin is taken from the bend of the elbow, the defect so caused may be closed by linear suture. Quite large areas may be re-surfaced as in this case of two fingers (Fig. 4) but one wonders if the patient would not have been better treated by partial closure with local skin and supplementary grafts as in this patient with three fingers injured (Fig. 5). The more fingers involved, the greater the need for preservation of length, a point to which I shall return later. Pulp L o s s
For pulp loss with exposure of the terminal phalanx, more than skin cover is required and this is the main indication for a thenar flap (Fig. 6). First described by Gatewood in 1926, the operation was revived by Flatt and a series reported in 1957. Patients must be selected; elderly patients and those in whom finger stiffness is a risk should be excluded. As the first stage, a small split skin graft of medium thickness is cut from the volar aspect of the forearm. The affected finger is flexed in its natural direction and the area of the thenar eminence which is brought into contact with the ampu,tated tip is used for the flap. In raising this some subcutaneous tissue is usually left behind as a bed for the split skin graft which is sutured to the edges of the defect. The thenar flap is carefully sutured to the margins of the deficiency on the finger and a small dressing applied firmly to the area of the free graft, before the finger is immobilised. The flap may be detached after two weeks. The result should show a good contour to the end of the finger and a symptomless donor area. In inexperienced hands failure may result in loss of the graft, a painful donor area or finger stiffness. The causes are wrong selection of patients, incorrect siting of the flap, positioning of the fingers too flexed or too extended (in the ideal position the flap is at right anglesto the thenar skin) and detachment of the flap too early or too late.
Fig. 6 Pulp loss treated by Thenar flap. Vol. 2
No. 2
1970
123
Finger Tip lnjuries--R. H. C. Robins
Fig. 7 Cross finger flap (a) in position (b) result of pulp repair on middle finger and (c) donor area on ring finger.
Figs. 8 and 9 124
Results of submammary flaps for fingers and thumb. Vol. 2
No. 2
1970
Finger Tip In]uries--R. H. C. Robins
An alternative to the thenar flap is the cross finger flap (Fig. 7). This has a more important application in re-surfacing the proximal and middle segments of the fingers. It may also be useful when the donor finger has also been damaged, but I am averse to using a normal finger when simpler alternatives are available. MULTIPLE INJURIES
My remarks hitherto have mostly applied to single finger injuries. When several digits have sustained terminal amputations and no local skin is available for closure, flaps from a distance may be necessary in order to avoid further shortening. Abdominal skin is too coarse for this purpose and the opposite arm or chest wall is preferable. The arm provides the best quality cover, but it is difficult to avoid a prominent scar. A carefully placed su,bmammary flap may be a suitable compromise. These examples show three finger tips replaced and the pulp of the thumb. As in the case of any routine flap replacement, sensibility is not transferred. otherwise there might be interesting side effects. One might rectify the loss of feeling in such a case with a primary neurovascular island flap, but the confluence of the right patient, with the right injury at the right time for the right surgeon is unlikely to occur very often. For those of you who are seeking news of recent advances in the surgery of the finger tip, Hueston in 1966 described a technique whereby skin from the volar surface of the finger is mobilised and transposed distally to cover the exposed stump of the digit with sensitive skin. The secondary defect at the base of the digit is then covered by a free graft. I have no personal experience of this procedure. I do not doubt its success in the capable hands of the originator, but the outcome of the only case of which I have any knowledge is now awaiting assessment by the Medical Defence Union. I end therefore as I began with a plea for sense and simplicity in the treatment of this, the commonest of all hand injuries.
ACKNOWLEDGEMENTS Figs. 1, 3, 4, 5, 7, 8 and 9 are reproduced by permission of Edward Arnold, publishers of Injuries and Infections of the Hand, R. H. C. Robins, 1961.
REFERENCES
FISHER, R. H. (1967) The Kutler Method of Repair of Finger Tip Amputations. Journal of Bone and Joint Surgery, 49A: 317. FLATT, A. E. (1957) The Thenar Flap. Journal of Bone and Joint Surgery, 39B: 80. GATEWOOD (1926) Unpublished. Personal communication from A. E. Flatt. HUESTON, J. T. (1966) Local Flap Repair of Fingertip Injuries. Plastic and Reconstructive Surgery, 37: 349. KUTLER, W. (1947) A new method for Finger Tip Amputations. Journal of the American Medical Association, 133: 29. MOBERG, E. (1958) Objective Methods of Determining the Functional Value of Sensibility in the Hand. Journal of Bone and Joint Surgery, 40B: 454. ROBINS, R. H. C. (1954) The Use of Post-Auricular Skin Grafts in the Treatment of Traumatic Amputation through the Terminal Compartment of the Finger. British Journal of Surgery, 41: 515. Vol. 2
No. 2
1970
125
TIP
INJURIES
R. H. C. ROBINS, Truro Not many years ago hand sepsis was the Cinderella of surgery and it was to deal with the large numbers of cases involved that special hand clinics were started in this country. Preventive measures, anti-biotics and more enlightened surgery have combined to reduce their frequency and to mitigate their seriousness. In contrast, the incidence of minor injuries of the hand has not diminished. It is probably true that major hand injuries command skilled attention anywhere, but minor ones often receive less than their due. High in this category comes trauma to the finger tips which in its various forms is likely to outnumber all other types of case. The difference between success and failure will not be evident by gross mutilation or deformity, but by lengthened disability period, by needless loss of function in a digit and occasionally by disabling pain. IMPORTANCE OF SENSIBILITY
I would remind you of the emphasis laid by Moberg (1958) on the function of the finger tip as an organ of sensibility, the third eye as he called it, and of investigation. If there is one message which I would convey to you it is this: as in life, it is quality that counts. There are many considerations in the treatment of cru,shed and amputated finger tips, including the preservation of maximum length, but if there is no feeling in the normal tactile area, if there is no cushioning of the soft tissue, if there is a tender scar or neuroma, that digit tends to get passed over and excluded from the regular use of the hand. Treatment therefore must aim to provide a finger tip which is free from pain and surfaced with robust skin, at least part of which has good sensibility. Sometimes this will involve sacrificing some length, a situation rarely disastrou,s if only one digit is involved. CAUSES OF FAILURE
Let us start by looking at a few causes of failure. Misplaced Optimism
An amputated part of a digit which consists of rather more than the tip i:~ unlikely to survive after being sewn back without the benefit of microvascular surgery. The first step in preservation is to determine the viability of the parts, a clinical judgment that should not be too difficult provided that the physical signs are not clouded by the use of a tourniquet. The second point is that delayed su.rgery is more difficult than primary repair, clean healing harder to achieve, while the ultimate loss of tissue may be greater. Equally an attempt to preserve tissue of doubtful viability, even if attached by a narrow strip of skin is unlikely to succeed. This type of flap might survive if thinned to the level of a full thickness graft. It is usually preferable to replace all or part of such a flap with a free graft. Expectant Treatment
Disappointment at the results of sewing back an amputated finger tip may lead to a trial of allowing nature to take its course. After remaining unhealed for weeks, secondary stiffness will develop, and reduce the chances of benefit from flap repair, which might have been successful in the first place. Vol. 2
No. 2 1970
119
Finger Tip lnjuries--R. H. C. Robins Poorly Fashioned Stump
A poorly fashioned end to the finger with adherent scar, deformed nail and atrophy of the pulp may be a cause of pain varying from hypersensitivity to touch to the severity of an amputation neuroma. Most of these cases which finish in prolonged litigation began with inadequate primary treatment. PRIMARY TREATMENT
How then is the primary treatment to be decided? I propose to devote the space allotted for this su~bject to two types of injury: compound fractures of the distal phalanx without gross loss of tissue, and terminal amputations. Compound Fractures
Compound fractures are generally caused by crushing of the finger tip, so that laceration and contusion of the pulp accompany the fracture, which may be cornminuted. The nail may be dislocated and the matrix torn. Surgery consists of debridement and closure of the wound making best use of the viable skin available. A few details need emphasis. Swelling is inevitable and post-operative gauze dressings must never be applied circumferentially. A dislocated nail should not be removed if it can be replaced and used as a splint for the fractured terminal phalanx. When the nail has been avulsed and the matrix lacerated, the raw area should be re-surfaced with a split skin graft. Haematoma under an intact nail should be released by trephining a hole. Small fragments of fractured phalanx may be removed, but the distal pulp mu.st not be left unsupported, a situation more likely to arise in the thumb than the fingers. Where children are concerned the powers of recovery are great and conservative treatment should be followed. In the more serious injuries, consideration must be given to formal amputation through the base of the terminal phalanx. The best interests of the patient, particularly an older manual worker, will not be served by the preservation of tissue of low vitality, especially if the nail fold is torn and one can predict that regrowth of the nail will result in deformity and dysfunction. At this point crush inju.ries cat, sing compound fractures merge with complete or partial terminal amputations and where the tissue loss is predominantly on the dorsum of the digit, a formal amputa-
Fig. 1 Amputation through the terminal segment of the ring finger. The digit is shown in full flexion. The scar is away from the important tactile area. 120
Fig. 2 A poorly shaped bulbous finger.
Vol. 2
No. 2 1970
Finger Tip ln}uries--R. H. C. Robins
Fig. 3 A split skin graft (left) compares favourably with a full thickness graft (right).
Fig. 4 Vol. 2
No. 2
1970
Two fingers treated by full thickness grafts. 121
Finger Tip lnjuries--R. H. C. Robins
tion is usually the treatment of choice. Closure of the wound is effected with a volar skin flap, so that the normal tactile skin of the digit covers the end of the stump. Careful removal of the nail fold is necessary or else small horns of nail will re-appear and another operation will be needed to eradicate them. Note here the difference between a well-shaped stump (Fig. 1) and a bulbous end with nail remnants (Fig. 2).
Amputations The primary treatment of amputations consists of the maintenance of as much length as is compatible with good skin cover. The choice of method will be decided by the age and occupation of the patient, the level and direction of amputation, the ratio of "cut to crush" caused by the injury and the tidiness or otherwise of the wound. The alternatives are closure by local flaps, application of free grafts, a combination of the two or the use of flaps from elsewhere in the hand or from a distance. In all instances the preliminary treatment is the same---debridement of the wound and reduction of any projecting bone to just below the level of the soft tissue. If a volar flap is used, some shortening of the digit is likely to be required and this may be unacceptable to the patient. There are other means available. V sections may be excised from the lateral margins of the skin to effect a fish-mouth closure. This has the disadvantage of a terminal scar, but the method is suitable when protection will later be afforded by growth of the nail. A re-appraisal has recently been made by Fisher (1967) of a method described by Kutler (1947) in which triangular flaps are developed on either side of the finger, the apex being directed proximally and the base along the line of the amputation. These flaps are mobilised to cover the top of the finger and the fish-mouth defects on either side are closed by linear suture. Free skin grafts provide the most generally applicable method of treatment for terminal amputations. When the defect is little more than skin deep, a split skin graft is quite adequate. The tiresome habit of contracting exhibited by this type of graft is an advantage in this situation. Over a period of months the surrounding normal skin is drawn distally so that the final area covered by graft is smaller than the original defect. The appearance of this finger tip compares favourably with this one for which the more usual full thickness graft has been used the injury being
Fig. 5 Multiple injuries treated by suture, supplemented by grafts to preserve all possible length. 122
Vol. 2
No. 2
1970
Finger Tip ln'luries--R. H. C. Robins
neither fresh, clean nor neatly incised and therefore unsuited to more elaborate surgery. Full thickness grafts must be trimmed of all subcutaneous fat and smured into position. It is difficult to divest oneself of previously published work. In 1954 I reported the results of a series of post-auricular skin grafts. I would like to take this opportunity of saying that I think this unnecessary and that the forearm provides a more appropriate donor area. If skin is taken from the bend of the elbow, the defect so caused may be closed by linear suture. Quite large areas may be re-surfaced as in this case of two fingers (Fig. 4) but one wonders if the patient would not have been better treated by partial closure with local skin and supplementary grafts as in this patient with three fingers injured (Fig. 5). The more fingers involved, the greater the need for preservation of length, a point to which I shall return later. Pulp L o s s
For pulp loss with exposure of the terminal phalanx, more than skin cover is required and this is the main indication for a thenar flap (Fig. 6). First described by Gatewood in 1926, the operation was revived by Flatt and a series reported in 1957. Patients must be selected; elderly patients and those in whom finger stiffness is a risk should be excluded. As the first stage, a small split skin graft of medium thickness is cut from the volar aspect of the forearm. The affected finger is flexed in its natural direction and the area of the thenar eminence which is brought into contact with the ampu,tated tip is used for the flap. In raising this some subcutaneous tissue is usually left behind as a bed for the split skin graft which is sutured to the edges of the defect. The thenar flap is carefully sutured to the margins of the deficiency on the finger and a small dressing applied firmly to the area of the free graft, before the finger is immobilised. The flap may be detached after two weeks. The result should show a good contour to the end of the finger and a symptomless donor area. In inexperienced hands failure may result in loss of the graft, a painful donor area or finger stiffness. The causes are wrong selection of patients, incorrect siting of the flap, positioning of the fingers too flexed or too extended (in the ideal position the flap is at right anglesto the thenar skin) and detachment of the flap too early or too late.
Fig. 6 Pulp loss treated by Thenar flap. Vol. 2
No. 2
1970
123
Finger Tip lnjuries--R. H. C. Robins
Fig. 7 Cross finger flap (a) in position (b) result of pulp repair on middle finger and (c) donor area on ring finger.
Figs. 8 and 9 124
Results of submammary flaps for fingers and thumb. Vol. 2
No. 2
1970
Finger Tip In]uries--R. H. C. Robins
An alternative to the thenar flap is the cross finger flap (Fig. 7). This has a more important application in re-surfacing the proximal and middle segments of the fingers. It may also be useful when the donor finger has also been damaged, but I am averse to using a normal finger when simpler alternatives are available. MULTIPLE INJURIES
My remarks hitherto have mostly applied to single finger injuries. When several digits have sustained terminal amputations and no local skin is available for closure, flaps from a distance may be necessary in order to avoid further shortening. Abdominal skin is too coarse for this purpose and the opposite arm or chest wall is preferable. The arm provides the best quality cover, but it is difficult to avoid a prominent scar. A carefully placed su,bmammary flap may be a suitable compromise. These examples show three finger tips replaced and the pulp of the thumb. As in the case of any routine flap replacement, sensibility is not transferred. otherwise there might be interesting side effects. One might rectify the loss of feeling in such a case with a primary neurovascular island flap, but the confluence of the right patient, with the right injury at the right time for the right surgeon is unlikely to occur very often. For those of you who are seeking news of recent advances in the surgery of the finger tip, Hueston in 1966 described a technique whereby skin from the volar surface of the finger is mobilised and transposed distally to cover the exposed stump of the digit with sensitive skin. The secondary defect at the base of the digit is then covered by a free graft. I have no personal experience of this procedure. I do not doubt its success in the capable hands of the originator, but the outcome of the only case of which I have any knowledge is now awaiting assessment by the Medical Defence Union. I end therefore as I began with a plea for sense and simplicity in the treatment of this, the commonest of all hand injuries.
ACKNOWLEDGEMENTS Figs. 1, 3, 4, 5, 7, 8 and 9 are reproduced by permission of Edward Arnold, publishers of Injuries and Infections of the Hand, R. H. C. Robins, 1961.
REFERENCES
FISHER, R. H. (1967) The Kutler Method of Repair of Finger Tip Amputations. Journal of Bone and Joint Surgery, 49A: 317. FLATT, A. E. (1957) The Thenar Flap. Journal of Bone and Joint Surgery, 39B: 80. GATEWOOD (1926) Unpublished. Personal communication from A. E. Flatt. HUESTON, J. T. (1966) Local Flap Repair of Fingertip Injuries. Plastic and Reconstructive Surgery, 37: 349. KUTLER, W. (1947) A new method for Finger Tip Amputations. Journal of the American Medical Association, 133: 29. MOBERG, E. (1958) Objective Methods of Determining the Functional Value of Sensibility in the Hand. Journal of Bone and Joint Surgery, 40B: 454. ROBINS, R. H. C. (1954) The Use of Post-Auricular Skin Grafts in the Treatment of Traumatic Amputation through the Terminal Compartment of the Finger. British Journal of Surgery, 41: 515. Vol. 2
No. 2
1970
125