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Management of partial fingertip amputation in adults: Operative and non operative treatment
G Model JINJ 7475 No. of Pages 7
Injury, Int. J. Care Injured xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Review
Management of partial fingertip amputation in adults: Operative and non operative treatment Kunal Sindhua , Steven F. DeFrodab,* , Andrew P. Harrisb , Joseph A. Gilb a b
Department of Medicine, Mount Sinai Beth Israel, New York, NY 10003, United States Department of Orthopaedic Surgery, Brown University, Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 0290, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 28 October 2017
Background: Hand and finger injuries account for approximately 4.8 million visits to emergency departments each year. These injuries can cause a great deal of distress for both patients and providers and are often initially encountered in urgent care clinics, community hospitals, and level one trauma centers. Tip amputation injuries vary widely in mechanism, ranging from sharp lacerations to crush injuries that present with varying degrees of contamination. The severity of damage to soft tissue, bone, arteries and nerves is dependent upon the mechanism and guides treatment decision-making. The management algorithm can oftentimes be complex, as a wide variety of providers, including orthopedists, general surgeons, plastic surgeons and emergency physicians, may care for these injuries, depending on location and local culture. We review the common mechanisms for tip amputation and the optimal treatment in adults, based on the severity of the injury, degree of wound contamination, and the facilities available to the provider. Methods: Pubmed was searched using text words for articles related to management of fingertip injuries in adults. Bibliographies of matching articles were searched for additional relevant articles, which were then also reviewed. 107 articles were reviewed in total, and 61 were deemed relevant for inclusion. All clinical studies and reviews were included. Particular attention was paid to articles published within the past 15 years. Results: In the United States, up to 90% of fingertip amputations are treated with non-replant techniques. In comparison, the majority of amputations in Asian countries are replanted due to moral values and importance of body integrity. Tip amputation injuries can be managed with local debridement, complex reconstruction, or simply with irrigation and application of a sterile dressing. Conclusion: In the United States, most fingertip amputations in adults are treated with non-replant techniques. However, the precise management of a fingertip injury in adults depends on the degree of injury itself, and a number of operative and non-operative techniques may be successfully employed. © 2017 Elsevier Ltd. All rights reserved.
Keywords: Finger Amputation Replant Soft tissue coverage
Contents Anatomy . . . . . . . . . . . . . . . Mechanism of injury . . . . . Sharp injury . . . . . . . . . Crush injury . . . . . . . . . Neurovascular injury . . Treatment . . . . . . . . . . . . . . Non-Operative . . . . . . . Antibiotics . . . . . . Local irrigation and Operative treatment . . . . . .
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* Corresponding author. E-mail address: [email protected] (S.F. DeFroda). https://doi.org/10.1016/j.injury.2017.10.042 0020-1383/© 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: K. Sindhu, et al., Management of partial fingertip amputation in adults: Operative and non operative treatment, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.042
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Nail bed repair . . . . . . . . . . . . . . . . . . . . Soft tissue coverage . . . . . . . . . . . . . . . . Revision tip amputation . . . . . . . . . . . . . Replantation . . . . . . . . . . . . . . . . . . . . . . Limitations of this literature review Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Anatomy
Mechanism of injury
The fingertip is composed of a thick layer of overlying skin, a core of pulp and bone, a protective fingernail, and branches of innervating nerves and supplying vessels. Numerous papillary ridges within the epidermis produce unique fingerprints in every individual. Multiple fibrous bands, interlaced with fat, make up the pulp and extend from the periosteum of the distal phalanx to the dermis [2]. The pulp makes up over half of the total volume of the fingertip and plays an important role in soft tissue coverage and in gripping objects [3]. Fingernails, which grow at an average rate of 0.1 millimeters per day, adorn the dorsal surface of each digit and perform a variety of functions. In addition to their cosmetic role, nails protect the dorsal surface of digits, increase the sensitivity of fingertips, and facilitate pinching and scratching [4]. Each nail is composed of an eponychium (or cuticle), paronychium, hyponychium, nail bed, nail plate, and nail root. The eponychium refers to the soft tissue at the proximal border of the nail, while the paronychium refers to the soft tissue at the lateral borders of the nail. The hyponychium is a keratinous plug located between the free distal edge of the nail and the fingertip that acts as a physical and immunological barrier to infection of the nail bed [5]. The nail bed consists of the proximal germinal matrix, which creates the keratin that composes the nail, and the distal sterile matrix, which is responsible for the nail’s adherence [6]. The junction between the germinal matrix and the sterile matrix is the lunula. The nail plate is composed of a keratinous substance called onchyn, which is produced by death of the germinal matrix cells. The proximal part of the nail plate is known as the nail root [3,7]. The digital vessels and nerves arborize near the distal interphalangeal (DIP) joint. Each main palmar digital artery sends branches to the nailbed and pulp [3,8]. The superficial palmar and oblique communicant veins drain deoxygenated blood from the palmar surface of the finger [8]. The digital arteries run along the sides of each digit, while the digital veins run along the dorsal surface of each digit. Each digital nerve, derived from either the median or ulnar nerve, sends branches to the paronychium, fingertip, and pulp volar to the corresponding digital artery. Given its importance in sensation, the fingertip is richly imbued with sensory receptors [9].
Sharp injury
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Injuries inflicted by sharp objects may result in laceration or amputation. Following careful examination, simple lacerations can typically be treated with primary closure in the emergency department after all nonviable tissue and dirt has been debrided [10]. Care should be taken to protect the wound until healing has occured [11,12]. If the nail is involved in the laceration, removal of the nail plate and exploration of the nail bed for potential repair is warranted [5]. Amputations are more complex injuries often affecting the fingertip, nail bed, and the neurovascular structures [5]. There are several fingertip injury classification systems including the Fassler, Rosenthal, Allen, Tamai, Sebastin and Chung, and most recently the PNB “(P)ulp, (N)erve, (B)one” system (Table 1) [3]. Evans and Bernadis proposed the PNB system using a point system to provide a 3-digit code to better describe injury severity to the pulp, nerves, and bone. One study has successfully used this classification to guide treatment, although another found it to be too complex for everyday clinical use [13]. Described in 1983, one of the most commonly used classifications is the Rosenthal system of fingertip amputations and is based on three zones: zone I injuries are distal to the bony phalanx, zone II injuries are between the lunula and distal phalanx, and zone III injuries are proximal to the lunula [14]. Zone I injuries can generally be treated conservatively because the germinal matrix remains intact. In contrast, zone II and III injuries do not spare the germinal matrix and are thus generally managed surgically [5]. Crush injury Crush injuries can present as open or closed and occur when compressive forces damage the fingertip [15]. While injuries to the pulp and bone may occur, they are generally self-limited and not associated with significant sequelae. Instead, the most critical consequence of crush injuries is damage to the nail bed, which can lead to altered nail growth, cosmetic deformity, and permanently decreased grip and scratch capabilities [10]. Clinicians often underestimate the severity of crush injuries and therefore delay the delivery of appropriate treatment. Therefore, it
Table 1 (P)ulp, (N)ail, and (B)one (PNB) Classification [3]. Pulp 0 1 2 3 4 5 6 7
No Injury Laceration Crush Loss – distal transverse Loss – palmar oblique partial Loss – dorsal oblique Loss – lateral Loss – complete
Nail
Bone
0 1 2 3 4 5 6 7 8
0 1 2 3 4 5 6 7 8
No Injury Sterile matrix laceration Germinal and sterile matrix laceration Crush Proximal nailbed dislocation Loss – distal third Loss – distal two thirds Loss – lateral Loss – complete
No Injury Tuft fracture Comminuted non-articular Articular involvement Displaced basal Tip exposure Loss – distal half Loss – subtotal Loss – complete
Please cite this article in press as: K. Sindhu, et al., Management of partial fingertip amputation in adults: Operative and non operative treatment, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.042
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is imperative that all physicians evaluating patients with these injuries have a low clinical threshold before undertaking more aggressive treatment measures. A simple radiograph of the crushed finger is critical as it provides information regarding the extent of the underlying bone and soft tissue injury that could be underappreciated on physical examination. Since 50% of nail bed injuries are associated with fractures of the distal phalanx, a fracture seen on radiograph can alert the physician to assess for damage of the nail bed [16]. A subungual hematoma can provide information, as well. A 1987 study found that 60% of patients with subungual hematoma comprising >50% of the nail had an associated nail bed laceration, and 95% of patients with concurrent subungual hematoma and distal phalanx fracture had an associated nail bed laceration [17,18]. With severe crush injuries, damage to both the sterile and germinal matrices may occur in conjunction. In these cases, and in others where the extent of damage to the nail bed is unknown, the nail should be removed and the nail bed should be examined [10,18]. The distal phalanx acts as a support that promotes the proper growth of the nail bed. Thus, in cases where a fracture has occurred, prompt reduction is essential to prevent long-term detrimental changes in nail growth, stability, and function. The most common fracture associated with a nail bed injury is a crush injury of the tuft of the distal phalanx. Most of these fractures are stable and can be treated with a splint to immobilize the affected finger for 3–4 weeks [18]. However, in more severe cases complicated by a displaced fracture, surgical fixation may be necessary [5,18,19]. Unfortunately, the seriousness of these fractures is frequently misjudged and undertreated, leading to significant long-term morbidity. Particularly difficult cases to diagnose are those in which the nail is avulsed from the proximal nail fold. These injuries, which often present in a benign manner, may mask an underlying open phalangeal fracture; if missed, the relocation of the nail plate and reduction of the fracture can be delayed [5].
Neurovascular injury Damage to neurovascular structures can occur with laceration, crush, or amputation injuries of the fingertip. Isolated neural damage in the finger produces sensory deficits, leaving motor function intact. The small size of the terminal branches of digital nerves can make the repair of these injuries challenging. If a nerve laceration is observed during the exploration of a fingertip injury, the injured nerve, if irreparable, should be dissected out and sharply transected as proximally as possible to prevent potential neuroma formation. In a retrospective study of digital nerve injuries by Van Der Avoort et al., the rate of symptomatic neuroma formation for patients with finger amputation was found to be 7.8% compared to 1% for patients without amputation that underwent nerve repair [20]. Although in comparison, Wilkens et al. found an unplanned reoperation rate of 44% for repair versus 21% for treatment with immediate revision amputation for combined finger injuries [21]. Injury to the digital arteries distal to the DIP joint is often successfully managed with a combination of continuous pressure and repair of the overlying skin laceration. If bleeding continues in spite of these interventions, a small suture may be used to tie off the damaged vessel if the contralateral digital artery is intact. However, care must be taken not to accidently tie off the adjacent digital nerve as well, which can cause significant pain due to neuroma formation [22]. Re-anastomosis procedures may be performed in the proximal aspect of the digits; however, repair distal to DIP joint is often challenging given that the digital arteries arborize distal to the DIP joint.
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Treatment Non-Operative Fingertip injuries characterized by small pulp defects (<1 cm2) and/or simple skin lacerations can generally be managed nonoperatively. Simple skin lacerations can typically be treated with primary closure in the emergency department using absorbable interrupted suture after irrigation and debridement of all nonviable tissue and dirt has occurred (Fig. 1) [10]. Loose approximation of the defect will allow for drainage of any remaining contaminants over time as the soft tissue heals by secondary intention. Alternatively, small superficial, uncontaminated pulp injuries without bone exposure may be treated in the emergency department with clinical follow up and serial dressing changes [3,4,11]. There are conflicting ideologies on coverage for fingertip injuries that argue over the need for definitive closure versus healing by secondary intention, but healing by secondary intention in select cases does appear to produce positive results. Allen et al. found that even more proximal amputations, through the lunula, would heal secondarily, but these injuries had a higher incidence of nail deformity [23]. Cold intolerance and changes in sensitivity were low, but more common in proximal injuries. Overall only 4 of 60 patients in the series were unhappy at a 6month follow-up, with zero patients having experienced a reduction in range of motion and only one having developed decreased grip strength [23]. Additionally, Lee et al. reviewed the functional outcomes in 156 patients with fingertip injuries [24]. The injuries were smaller (<1 cm in diameter), but 63% of patients did have injuries in which bone was exposed. The only intervention performed was shortening of the bone at the time of injury to the level of the fat to allow healing by secondary intention. The average time to healing was 32 days and 85% of laborers returned to work within 1 month [24]. Healing time, aesthetic result, sensation, infection, and grip strength are the most common outcome measures tracked in the evaluation of the efficacy of successful non-operative management. On average, complete wound healing can be expected by 4 weeks, while defects <1 cm with no bony defect may heal as quickly as two weeks [25–27]. Most patients are ultimately pleased with their cosmetic outcome. The finger pulp has been shown to
Fig. 1. Acute Repair of complex distal thumb crush injury with absorbable suture.
Please cite this article in press as: K. Sindhu, et al., Management of partial fingertip amputation in adults: Operative and non operative treatment, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.042
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elongate 6–7 mm with healing, even in the case of exposed bone due to the thick fat of the fingertip being pulled over the bone by the glaborous skin during secondary healing [27]. Nail deformity is the most common complaint. A systematic review of 1592 fingertip amputations by Yuan et al. reported on a multitude of complications and found that 6% of patients have residual nail defects [27]. Hook nail occurs most commonly in more proximal injuries, but also may occur even with surgical management with a flap [28]. Sensation has been found to return to levels comparable to the uninjured hand in a majority of patients [18,23,24]. Cold intolerance can be a significant issue, with rates reported as high as 86% at 2 months; however, it frequently resolves by 1 year [26,28]. Infection is rare, and if it does occur it is generally superficial in nature. One large review of the non-operative management of finger injuries did not report a single episode of osteomyelitis [27]. Grip strength and range of motion can actually be better in nonoperative patients due to the lack of need for immobilization, which generally causes joint stiffness [29]. Due to the shorter finger length, pinch strength and fine motor skills may be diminished [30]. Antibiotics Antibiotics are often used prophylactically in immunocompromised patients and those with contaminated wounds. However, antibiotic use, even in these patients, is controversial [31]. A metaanalysis by De Alwis et al. did not find any RCTs that specifically looked at antibiotic use in patients with fingertip injuries. However, several studies looked at antibiotic use in patients with soft tissue injuries of the hand [10]. In one study of 104 patients with clean wounds on the fingers and thumb and 40 patients with clean wounds on the palm and wrist, there was no statistically significant difference in infection rate between the antibiotic treatment and placebo groups [32]. Studies examining prophylactic antibiotic treatment in patients with open distal phalanx fractures have yielded conflicting results [33,34]. One randomized controlled trial (RCT) revealed no difference in infection rates between treated and non-treated groups, while another showed a significant increase in infection rate in patients not treated with antibiotics [10,35]. Rubin et al. looked at prophylactic antibiotic use in patients with fingertip amputations complicated by bone exposure. No statistically significant difference in infection rate between the antibiotic and control groups was found [31]. These studies demonstrate that early, thorough wound care, rather than prophylactic antibiotic use, appears to be the most important factor in preventing future infections in patients with fingertip injuries [10,31]. Local irrigation and debridement Early wound care plays an important role in the management of these cases, and may in fact be the most important factor in preventing infections from developing [10]. Thus, fingertip injuries should be thoroughly cleaned with copious amounts of normal saline and all non-viable soft tissue should be debrided in the emergency department [4,10,11,36]. Digital nerve block, proper sterile technique, and care to avoid the nail bed during debridement are essential. In patients who are not adequately immunized, anti-tetanus prophylaxis is warranted [10].
at repair to ensure that the germinal matrix has not been compromised [36]. Cases characterized by complex lacerations of the nail bed, loss of portions of the nail bed, or avulsions of the nail fold should be referred to a hand surgeon for further management [4,12,36]. Dermabond, or 2-octylcyanoacrylate, has been proposed as an alternative to absorbable suture as a method to conservatively repair simple nail bed injuries. Of note, 2-octylcyanoacrylate is believed to offer faster repair times and strength equivalent to that of a standard 4-0 Monocryl suture [37]. Clinical studies have backed these claims. Singer et al. found that patients treated with this novel approach had similar cosmetic results and infection rates as patients treated with standard suture [38]. Strauss et. al found a 66% reduction in repair time using 2-octylcyanoacrylate as compared to standard suture, with similar cosmetic and functional outcomes in groups treated with either method [39]. Injuries to the nail bed are frequently complicated by the formation of subungual hematomas, which can cause severe pain [5]. In cases where the nail has not been displaced from the nail fold and there is certainty that no damage has occurred to the nail bed or distal phalanx, conservative management in the emergency department with trephination for pain relief is sufficient [5,10]. However, if there is any question of damage to the nail bed or fracture of the distal phalanx, removal of the nail bed, followed by its repair and reduction of any associated fracture, is necessary [5]. A consultation with a hand surgeon may be necessary if the nailbed is involved [4,36]. Acrylic nails should be removed and explored in the emergency department if underlying trauma is suspected [40]. Soft tissue coverage Patients with large and volar oblique injuries, exposed bone, and associated distal phalanx fractures will often require flap coverage [41]. The choice of the flap utilized depends primarily on the digit involved and the shape and size of the wound [3]. Terminal pulp V-Y flaps, also known as Atasoy flaps, are most effective in repairing small (<1 cm2) dorsal oblique and transverse injuries; they cannot be used for volar oblique injuries [42,43]. The distal edge of the wound serves as the triangular flap’s base, whose apex is extended to the crease of the DIP joint. The skin and subcutaneous tissue are then gently dissected and the flap’s edges are loosely sutured in an effort to avoid neurovascular injury [18]. Both cross-finger and thenar flaps may be used to treat volar oblique injuries and require 10–14 days of post-procedure immobilization [3,42]. Thenar flaps, however, are generally used for injuries to the second and third digits, while cross-finger flaps may be used for injuries to any digit. The thenar flap is first created with its radial border parallel to the crease of the MCP joint. As the flap is elevated distally, care is taken to remain superficial to avoid injury to radial digital nerve [18,42]. In contrast, the cross-finger flap is a rectangular flap that is designed over the middle phalanx of the donor digit. Its hinge, which is located adjacent to the injured digit, is reflected and sutured to the primary defect. A fullthickness skin graft is used to repair the donor site [3,18,42]. A 2016 study by Rabarin et al. of 22 patients who had received cross-finger flaps reported positive long-term outcomes. Distal sensitivity, without pain or neuromas, was maintained in every examined patient. 32% reported cold intolerance [44].
Operative treatment Revision tip amputation Nail bed repair Simple lacerations affecting the sterile matrix or nail folds in adults may be conservatively treated in the emergency department using absorbable sutures [10–12,36]. Proximal injuries, however, must be visualized and thoroughly assessed prior to any attempts
Digits amputated in zone 2, proximal to the insertion of the flexor digitorum superficialis, are generally not replanted because of the risk of subsequently developing stiffness, which can interfere with hand function, is high [13]. Rather, revising the amputation, which is simpler, cheaper, and associated with better
Please cite this article in press as: K. Sindhu, et al., Management of partial fingertip amputation in adults: Operative and non operative treatment, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.042
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functional outcomes than replantation in these patients, is preferred (Fig. 2) [45]. Patients tolerate the procedure well and recover quickly, returning to work in 47 days on average, or approximately 1.5 months, as compared to 3.2–4.0 months after replantation [30,46,47]. Revisions may also be considered in older patients and in those with complex systemic comorbidities [48]. Revisions have been found to produce better sensory and functional outcomes than local flap treatments. However, revisions are associated with the highest rates of cold intolerance of any fingertip injury treatment. Interestingly, a 2015 systematic review by Yuan et al. found no significant differences among patients who have received conservative, revision amputation, or local flap treatment [49]. However, a 2014 literature review by Peterson et al. found better functional outcomes associated with replantation versus amputation revision, and little to no advantages from flap reconstruction over healing by secondary intention generally [3]. Replantation Replantation may be considered in some cases of fingertip amputation if normal architecture is preserved such as occurs in a sharp injury mechanism [10]. A vascular anastomosis is often required to produce a viable replanted fingertip (Fig. 3) [18,50]. Immediately following the injury, the amputated digit should be wrapped in sterile gauze soaked in normal saline, placed in a plastic bag, and then stored in a mix of ice and water as the patient is transported to the emergency department [10,55]. Amputated fingertips, due to their lack of muscular tissue, can stay viable for long periods of time: up to 6–12 h in cases of warm ischemia and 24–30 h in cases of cold ischemia [51–53]. Digital replantation is currently indicated for injuries involving the thumb, single digits distal to the insertion of the flexor digitorum superficialis tendon, and multiple digits [18,54]. A 2011 systematic review by Sebastin and Chung found a mean survival rate of 86% associated with 2273 distal digital replantations. No differences were found between zone I and II replantations, but successful repair of a vein and a clean-cut injuries were associated with better outcomes [13]. Contraindications for replantation include cases in which digits are severely damaged by crush or contamination mechanisms, the presence of peripheral vascular disease, and the presence of systemic diseases associated with vascular compromise [55]. While the scope of amputation cases that fall under the indications for replantation is vast, the operating surgeon must make his or her decision to proceed with the procedure based on the probability of a successful functional and cosmetic outcome [53]. Numerous factors have been found to influence this process. Digits that have undergone clean-cut amputation tend to have significantly better restorative outcomes than digits that have been crushed or avulsed [56]. Additionally, warm ischemia time of less
Fig. 3. Thump replantation procedure. Vascular anastomosis is crucial to the success of this figure. Not the digital artery (white arrow) intact proximally.
than 12 h, or cold ischemia time of less than 30 h, is associated with higher success rates [53]. Digital injuries in elderly patients, who are more likely to suffer from numerous systemic comorbidities that interfere with proper healing, and males, who may experience more severe injuries, tend to have lower success rates than those in younger and female patients, respectively [53,57]. While alcohol consumption does not appear to influence the success rate of digit replantation, smoking is associated with poorer results overall as nicotine is a well-known vasoconstrictor; in fact, the replanted digits of non-smokers have a survival rate that is 11.8 times higher than that of smokers [57]. Lastly, patients with atherosclerosis, autoimmune diseases, connective tissue diseases, and diabetes mellitus, all signs of potential vascular compromise, tend to be prone to poor results [53]. In cases of amputation, bone and tendon injuries should generally be repaired first. Following successful tendon repair, extensive arterial and venous repair is indicated as prior work has shown that overall replantation results are correlated with the number of vessels repaired. Digital nerve repair should be addressed last. Epineural sutures are generally sufficient for this process, but nerve grafts may be necessary [52]. Regardless of repair, cold intolerance and painful neuroma formation are potential sequela of digital nerve injury [10,26]. When replantation is not possible, composite grafting may be considered. In this procedure, the amputated tip is directly sutured to its parent finger after both ends have been thoroughly cleansed and debrided. While composite grafting has historically been used most frequently in young children, there is some evidence to
Fig. 2. A. Patient with multiple partial fingertip amputations following a lawn mower injury. B, C. The patients wounds were irrigate in the emergency department and revision amputation was performed to debride injured bone and soft tissue and to provide adequate soft tissue coverage.
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support its use in adults. However, by its nature, the indications for the use of composite grafting is limited to certain select cases of injury [3,18]. In those patients who cannot undergo composite grafting, wound closure by secondary intention or surgery may also be considered [3]. For defects smaller than 1.5 cm2 with no bone exposure, healing by secondary intention and surgical reconstruction appear to be equally efficacious in terms of healing and functional outcomes [27,42]. As a result, the vast majority of fingertip injuries are treated conservatively [41]. Treating fingertip amputations by secondary intention may involve the use of occlusive, semiocclusive and simple adherent sterile dressings, and subatmospheric wound therapy [58,59]. Semiocclusive dressing, in particular, has gained popularity in recent years. The wound is dressed after cleaning and debridement, and weekly wound cleaning and dressing changes are initiated. Patients are instructed to continue to use the affected hand as they normally would, without immobilization. Wound closure, accompanied by a recovery in sensation, occurs within 2–8 weeks [43]. While treatment with secondary intention is generally successful in indicated patients, care must be taken in patients with bone shortening, in which support for the nail is compromised. In these patients, in order to avoid the development of the hook nail deformity as the wound closes, care must be undertaken to excise the nail bed 2 mm proximal to the shortened bone [3,60]. In patients who cannot maintain an open wound for an extended period of time, skin grafts may be utilized. However, grafts do not necessarily always lead to favorable outcomes in all patients and may instead result in greater cold intolerance, compromised durability, and persistent tenderness [3,58].
Limitations of this literature review This review was limited to the management of fingertip injuries in adults. As such, it does not cover injuries of the hand more generally. Additionally, it does not include fingertip injuries in children, whose management can vary significantly from that of a more mature population. Moreover, this review covers only the most common techniques used to manage fingertip injuries that have been studied over time. Newer emerging, or experimental, techniques are not included. Conclusion Hand and finger injuries are not an uncommon occurrence in the United States, accounting for approximately 4.8 million visits to emergency departments each year [1]. Traumatic finger amputations of varying zones total approximately 45,000 cases annually [49]. Since the fingertip performs complex sensory and aesthetic functions, the proper management of these injuries is crucial. All fingertip injuries should be thoroughly cleaned and debrided. While both sharp and crush injuries may present unique challenges, physicians must ensure that patients with crush injuries are thoroughly examined for nail bed injuries and distal phalangeal fractures, as these can lead to significant long-term morbidity if left untreated. The precise treatment strategy, whether conservative or operative, primarily depends on the extent of the injury and must be determined on a case-by-case basis. Funding The authors have no financial disclosures or conflicts or competing interests to report.
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Injury, Int. J. Care Injured xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Review
Management of partial fingertip amputation in adults: Operative and non operative treatment Kunal Sindhua , Steven F. DeFrodab,* , Andrew P. Harrisb , Joseph A. Gilb a b
Department of Medicine, Mount Sinai Beth Israel, New York, NY 10003, United States Department of Orthopaedic Surgery, Brown University, Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 0290, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 28 October 2017
Background: Hand and finger injuries account for approximately 4.8 million visits to emergency departments each year. These injuries can cause a great deal of distress for both patients and providers and are often initially encountered in urgent care clinics, community hospitals, and level one trauma centers. Tip amputation injuries vary widely in mechanism, ranging from sharp lacerations to crush injuries that present with varying degrees of contamination. The severity of damage to soft tissue, bone, arteries and nerves is dependent upon the mechanism and guides treatment decision-making. The management algorithm can oftentimes be complex, as a wide variety of providers, including orthopedists, general surgeons, plastic surgeons and emergency physicians, may care for these injuries, depending on location and local culture. We review the common mechanisms for tip amputation and the optimal treatment in adults, based on the severity of the injury, degree of wound contamination, and the facilities available to the provider. Methods: Pubmed was searched using text words for articles related to management of fingertip injuries in adults. Bibliographies of matching articles were searched for additional relevant articles, which were then also reviewed. 107 articles were reviewed in total, and 61 were deemed relevant for inclusion. All clinical studies and reviews were included. Particular attention was paid to articles published within the past 15 years. Results: In the United States, up to 90% of fingertip amputations are treated with non-replant techniques. In comparison, the majority of amputations in Asian countries are replanted due to moral values and importance of body integrity. Tip amputation injuries can be managed with local debridement, complex reconstruction, or simply with irrigation and application of a sterile dressing. Conclusion: In the United States, most fingertip amputations in adults are treated with non-replant techniques. However, the precise management of a fingertip injury in adults depends on the degree of injury itself, and a number of operative and non-operative techniques may be successfully employed. © 2017 Elsevier Ltd. All rights reserved.
Keywords: Finger Amputation Replant Soft tissue coverage
Contents Anatomy . . . . . . . . . . . . . . . Mechanism of injury . . . . . Sharp injury . . . . . . . . . Crush injury . . . . . . . . . Neurovascular injury . . Treatment . . . . . . . . . . . . . . Non-Operative . . . . . . . Antibiotics . . . . . . Local irrigation and Operative treatment . . . . . .
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* Corresponding author. E-mail address: [email protected] (S.F. DeFroda). https://doi.org/10.1016/j.injury.2017.10.042 0020-1383/© 2017 Elsevier Ltd. All rights reserved.
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Nail bed repair . . . . . . . . . . . . . . . . . . . . Soft tissue coverage . . . . . . . . . . . . . . . . Revision tip amputation . . . . . . . . . . . . . Replantation . . . . . . . . . . . . . . . . . . . . . . Limitations of this literature review Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Anatomy
Mechanism of injury
The fingertip is composed of a thick layer of overlying skin, a core of pulp and bone, a protective fingernail, and branches of innervating nerves and supplying vessels. Numerous papillary ridges within the epidermis produce unique fingerprints in every individual. Multiple fibrous bands, interlaced with fat, make up the pulp and extend from the periosteum of the distal phalanx to the dermis [2]. The pulp makes up over half of the total volume of the fingertip and plays an important role in soft tissue coverage and in gripping objects [3]. Fingernails, which grow at an average rate of 0.1 millimeters per day, adorn the dorsal surface of each digit and perform a variety of functions. In addition to their cosmetic role, nails protect the dorsal surface of digits, increase the sensitivity of fingertips, and facilitate pinching and scratching [4]. Each nail is composed of an eponychium (or cuticle), paronychium, hyponychium, nail bed, nail plate, and nail root. The eponychium refers to the soft tissue at the proximal border of the nail, while the paronychium refers to the soft tissue at the lateral borders of the nail. The hyponychium is a keratinous plug located between the free distal edge of the nail and the fingertip that acts as a physical and immunological barrier to infection of the nail bed [5]. The nail bed consists of the proximal germinal matrix, which creates the keratin that composes the nail, and the distal sterile matrix, which is responsible for the nail’s adherence [6]. The junction between the germinal matrix and the sterile matrix is the lunula. The nail plate is composed of a keratinous substance called onchyn, which is produced by death of the germinal matrix cells. The proximal part of the nail plate is known as the nail root [3,7]. The digital vessels and nerves arborize near the distal interphalangeal (DIP) joint. Each main palmar digital artery sends branches to the nailbed and pulp [3,8]. The superficial palmar and oblique communicant veins drain deoxygenated blood from the palmar surface of the finger [8]. The digital arteries run along the sides of each digit, while the digital veins run along the dorsal surface of each digit. Each digital nerve, derived from either the median or ulnar nerve, sends branches to the paronychium, fingertip, and pulp volar to the corresponding digital artery. Given its importance in sensation, the fingertip is richly imbued with sensory receptors [9].
Sharp injury
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Injuries inflicted by sharp objects may result in laceration or amputation. Following careful examination, simple lacerations can typically be treated with primary closure in the emergency department after all nonviable tissue and dirt has been debrided [10]. Care should be taken to protect the wound until healing has occured [11,12]. If the nail is involved in the laceration, removal of the nail plate and exploration of the nail bed for potential repair is warranted [5]. Amputations are more complex injuries often affecting the fingertip, nail bed, and the neurovascular structures [5]. There are several fingertip injury classification systems including the Fassler, Rosenthal, Allen, Tamai, Sebastin and Chung, and most recently the PNB “(P)ulp, (N)erve, (B)one” system (Table 1) [3]. Evans and Bernadis proposed the PNB system using a point system to provide a 3-digit code to better describe injury severity to the pulp, nerves, and bone. One study has successfully used this classification to guide treatment, although another found it to be too complex for everyday clinical use [13]. Described in 1983, one of the most commonly used classifications is the Rosenthal system of fingertip amputations and is based on three zones: zone I injuries are distal to the bony phalanx, zone II injuries are between the lunula and distal phalanx, and zone III injuries are proximal to the lunula [14]. Zone I injuries can generally be treated conservatively because the germinal matrix remains intact. In contrast, zone II and III injuries do not spare the germinal matrix and are thus generally managed surgically [5]. Crush injury Crush injuries can present as open or closed and occur when compressive forces damage the fingertip [15]. While injuries to the pulp and bone may occur, they are generally self-limited and not associated with significant sequelae. Instead, the most critical consequence of crush injuries is damage to the nail bed, which can lead to altered nail growth, cosmetic deformity, and permanently decreased grip and scratch capabilities [10]. Clinicians often underestimate the severity of crush injuries and therefore delay the delivery of appropriate treatment. Therefore, it
Table 1 (P)ulp, (N)ail, and (B)one (PNB) Classification [3]. Pulp 0 1 2 3 4 5 6 7
No Injury Laceration Crush Loss – distal transverse Loss – palmar oblique partial Loss – dorsal oblique Loss – lateral Loss – complete
Nail
Bone
0 1 2 3 4 5 6 7 8
0 1 2 3 4 5 6 7 8
No Injury Sterile matrix laceration Germinal and sterile matrix laceration Crush Proximal nailbed dislocation Loss – distal third Loss – distal two thirds Loss – lateral Loss – complete
No Injury Tuft fracture Comminuted non-articular Articular involvement Displaced basal Tip exposure Loss – distal half Loss – subtotal Loss – complete
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is imperative that all physicians evaluating patients with these injuries have a low clinical threshold before undertaking more aggressive treatment measures. A simple radiograph of the crushed finger is critical as it provides information regarding the extent of the underlying bone and soft tissue injury that could be underappreciated on physical examination. Since 50% of nail bed injuries are associated with fractures of the distal phalanx, a fracture seen on radiograph can alert the physician to assess for damage of the nail bed [16]. A subungual hematoma can provide information, as well. A 1987 study found that 60% of patients with subungual hematoma comprising >50% of the nail had an associated nail bed laceration, and 95% of patients with concurrent subungual hematoma and distal phalanx fracture had an associated nail bed laceration [17,18]. With severe crush injuries, damage to both the sterile and germinal matrices may occur in conjunction. In these cases, and in others where the extent of damage to the nail bed is unknown, the nail should be removed and the nail bed should be examined [10,18]. The distal phalanx acts as a support that promotes the proper growth of the nail bed. Thus, in cases where a fracture has occurred, prompt reduction is essential to prevent long-term detrimental changes in nail growth, stability, and function. The most common fracture associated with a nail bed injury is a crush injury of the tuft of the distal phalanx. Most of these fractures are stable and can be treated with a splint to immobilize the affected finger for 3–4 weeks [18]. However, in more severe cases complicated by a displaced fracture, surgical fixation may be necessary [5,18,19]. Unfortunately, the seriousness of these fractures is frequently misjudged and undertreated, leading to significant long-term morbidity. Particularly difficult cases to diagnose are those in which the nail is avulsed from the proximal nail fold. These injuries, which often present in a benign manner, may mask an underlying open phalangeal fracture; if missed, the relocation of the nail plate and reduction of the fracture can be delayed [5].
Neurovascular injury Damage to neurovascular structures can occur with laceration, crush, or amputation injuries of the fingertip. Isolated neural damage in the finger produces sensory deficits, leaving motor function intact. The small size of the terminal branches of digital nerves can make the repair of these injuries challenging. If a nerve laceration is observed during the exploration of a fingertip injury, the injured nerve, if irreparable, should be dissected out and sharply transected as proximally as possible to prevent potential neuroma formation. In a retrospective study of digital nerve injuries by Van Der Avoort et al., the rate of symptomatic neuroma formation for patients with finger amputation was found to be 7.8% compared to 1% for patients without amputation that underwent nerve repair [20]. Although in comparison, Wilkens et al. found an unplanned reoperation rate of 44% for repair versus 21% for treatment with immediate revision amputation for combined finger injuries [21]. Injury to the digital arteries distal to the DIP joint is often successfully managed with a combination of continuous pressure and repair of the overlying skin laceration. If bleeding continues in spite of these interventions, a small suture may be used to tie off the damaged vessel if the contralateral digital artery is intact. However, care must be taken not to accidently tie off the adjacent digital nerve as well, which can cause significant pain due to neuroma formation [22]. Re-anastomosis procedures may be performed in the proximal aspect of the digits; however, repair distal to DIP joint is often challenging given that the digital arteries arborize distal to the DIP joint.
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Treatment Non-Operative Fingertip injuries characterized by small pulp defects (<1 cm2) and/or simple skin lacerations can generally be managed nonoperatively. Simple skin lacerations can typically be treated with primary closure in the emergency department using absorbable interrupted suture after irrigation and debridement of all nonviable tissue and dirt has occurred (Fig. 1) [10]. Loose approximation of the defect will allow for drainage of any remaining contaminants over time as the soft tissue heals by secondary intention. Alternatively, small superficial, uncontaminated pulp injuries without bone exposure may be treated in the emergency department with clinical follow up and serial dressing changes [3,4,11]. There are conflicting ideologies on coverage for fingertip injuries that argue over the need for definitive closure versus healing by secondary intention, but healing by secondary intention in select cases does appear to produce positive results. Allen et al. found that even more proximal amputations, through the lunula, would heal secondarily, but these injuries had a higher incidence of nail deformity [23]. Cold intolerance and changes in sensitivity were low, but more common in proximal injuries. Overall only 4 of 60 patients in the series were unhappy at a 6month follow-up, with zero patients having experienced a reduction in range of motion and only one having developed decreased grip strength [23]. Additionally, Lee et al. reviewed the functional outcomes in 156 patients with fingertip injuries [24]. The injuries were smaller (<1 cm in diameter), but 63% of patients did have injuries in which bone was exposed. The only intervention performed was shortening of the bone at the time of injury to the level of the fat to allow healing by secondary intention. The average time to healing was 32 days and 85% of laborers returned to work within 1 month [24]. Healing time, aesthetic result, sensation, infection, and grip strength are the most common outcome measures tracked in the evaluation of the efficacy of successful non-operative management. On average, complete wound healing can be expected by 4 weeks, while defects <1 cm with no bony defect may heal as quickly as two weeks [25–27]. Most patients are ultimately pleased with their cosmetic outcome. The finger pulp has been shown to
Fig. 1. Acute Repair of complex distal thumb crush injury with absorbable suture.
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elongate 6–7 mm with healing, even in the case of exposed bone due to the thick fat of the fingertip being pulled over the bone by the glaborous skin during secondary healing [27]. Nail deformity is the most common complaint. A systematic review of 1592 fingertip amputations by Yuan et al. reported on a multitude of complications and found that 6% of patients have residual nail defects [27]. Hook nail occurs most commonly in more proximal injuries, but also may occur even with surgical management with a flap [28]. Sensation has been found to return to levels comparable to the uninjured hand in a majority of patients [18,23,24]. Cold intolerance can be a significant issue, with rates reported as high as 86% at 2 months; however, it frequently resolves by 1 year [26,28]. Infection is rare, and if it does occur it is generally superficial in nature. One large review of the non-operative management of finger injuries did not report a single episode of osteomyelitis [27]. Grip strength and range of motion can actually be better in nonoperative patients due to the lack of need for immobilization, which generally causes joint stiffness [29]. Due to the shorter finger length, pinch strength and fine motor skills may be diminished [30]. Antibiotics Antibiotics are often used prophylactically in immunocompromised patients and those with contaminated wounds. However, antibiotic use, even in these patients, is controversial [31]. A metaanalysis by De Alwis et al. did not find any RCTs that specifically looked at antibiotic use in patients with fingertip injuries. However, several studies looked at antibiotic use in patients with soft tissue injuries of the hand [10]. In one study of 104 patients with clean wounds on the fingers and thumb and 40 patients with clean wounds on the palm and wrist, there was no statistically significant difference in infection rate between the antibiotic treatment and placebo groups [32]. Studies examining prophylactic antibiotic treatment in patients with open distal phalanx fractures have yielded conflicting results [33,34]. One randomized controlled trial (RCT) revealed no difference in infection rates between treated and non-treated groups, while another showed a significant increase in infection rate in patients not treated with antibiotics [10,35]. Rubin et al. looked at prophylactic antibiotic use in patients with fingertip amputations complicated by bone exposure. No statistically significant difference in infection rate between the antibiotic and control groups was found [31]. These studies demonstrate that early, thorough wound care, rather than prophylactic antibiotic use, appears to be the most important factor in preventing future infections in patients with fingertip injuries [10,31]. Local irrigation and debridement Early wound care plays an important role in the management of these cases, and may in fact be the most important factor in preventing infections from developing [10]. Thus, fingertip injuries should be thoroughly cleaned with copious amounts of normal saline and all non-viable soft tissue should be debrided in the emergency department [4,10,11,36]. Digital nerve block, proper sterile technique, and care to avoid the nail bed during debridement are essential. In patients who are not adequately immunized, anti-tetanus prophylaxis is warranted [10].
at repair to ensure that the germinal matrix has not been compromised [36]. Cases characterized by complex lacerations of the nail bed, loss of portions of the nail bed, or avulsions of the nail fold should be referred to a hand surgeon for further management [4,12,36]. Dermabond, or 2-octylcyanoacrylate, has been proposed as an alternative to absorbable suture as a method to conservatively repair simple nail bed injuries. Of note, 2-octylcyanoacrylate is believed to offer faster repair times and strength equivalent to that of a standard 4-0 Monocryl suture [37]. Clinical studies have backed these claims. Singer et al. found that patients treated with this novel approach had similar cosmetic results and infection rates as patients treated with standard suture [38]. Strauss et. al found a 66% reduction in repair time using 2-octylcyanoacrylate as compared to standard suture, with similar cosmetic and functional outcomes in groups treated with either method [39]. Injuries to the nail bed are frequently complicated by the formation of subungual hematomas, which can cause severe pain [5]. In cases where the nail has not been displaced from the nail fold and there is certainty that no damage has occurred to the nail bed or distal phalanx, conservative management in the emergency department with trephination for pain relief is sufficient [5,10]. However, if there is any question of damage to the nail bed or fracture of the distal phalanx, removal of the nail bed, followed by its repair and reduction of any associated fracture, is necessary [5]. A consultation with a hand surgeon may be necessary if the nailbed is involved [4,36]. Acrylic nails should be removed and explored in the emergency department if underlying trauma is suspected [40]. Soft tissue coverage Patients with large and volar oblique injuries, exposed bone, and associated distal phalanx fractures will often require flap coverage [41]. The choice of the flap utilized depends primarily on the digit involved and the shape and size of the wound [3]. Terminal pulp V-Y flaps, also known as Atasoy flaps, are most effective in repairing small (<1 cm2) dorsal oblique and transverse injuries; they cannot be used for volar oblique injuries [42,43]. The distal edge of the wound serves as the triangular flap’s base, whose apex is extended to the crease of the DIP joint. The skin and subcutaneous tissue are then gently dissected and the flap’s edges are loosely sutured in an effort to avoid neurovascular injury [18]. Both cross-finger and thenar flaps may be used to treat volar oblique injuries and require 10–14 days of post-procedure immobilization [3,42]. Thenar flaps, however, are generally used for injuries to the second and third digits, while cross-finger flaps may be used for injuries to any digit. The thenar flap is first created with its radial border parallel to the crease of the MCP joint. As the flap is elevated distally, care is taken to remain superficial to avoid injury to radial digital nerve [18,42]. In contrast, the cross-finger flap is a rectangular flap that is designed over the middle phalanx of the donor digit. Its hinge, which is located adjacent to the injured digit, is reflected and sutured to the primary defect. A fullthickness skin graft is used to repair the donor site [3,18,42]. A 2016 study by Rabarin et al. of 22 patients who had received cross-finger flaps reported positive long-term outcomes. Distal sensitivity, without pain or neuromas, was maintained in every examined patient. 32% reported cold intolerance [44].
Operative treatment Revision tip amputation Nail bed repair Simple lacerations affecting the sterile matrix or nail folds in adults may be conservatively treated in the emergency department using absorbable sutures [10–12,36]. Proximal injuries, however, must be visualized and thoroughly assessed prior to any attempts
Digits amputated in zone 2, proximal to the insertion of the flexor digitorum superficialis, are generally not replanted because of the risk of subsequently developing stiffness, which can interfere with hand function, is high [13]. Rather, revising the amputation, which is simpler, cheaper, and associated with better
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functional outcomes than replantation in these patients, is preferred (Fig. 2) [45]. Patients tolerate the procedure well and recover quickly, returning to work in 47 days on average, or approximately 1.5 months, as compared to 3.2–4.0 months after replantation [30,46,47]. Revisions may also be considered in older patients and in those with complex systemic comorbidities [48]. Revisions have been found to produce better sensory and functional outcomes than local flap treatments. However, revisions are associated with the highest rates of cold intolerance of any fingertip injury treatment. Interestingly, a 2015 systematic review by Yuan et al. found no significant differences among patients who have received conservative, revision amputation, or local flap treatment [49]. However, a 2014 literature review by Peterson et al. found better functional outcomes associated with replantation versus amputation revision, and little to no advantages from flap reconstruction over healing by secondary intention generally [3]. Replantation Replantation may be considered in some cases of fingertip amputation if normal architecture is preserved such as occurs in a sharp injury mechanism [10]. A vascular anastomosis is often required to produce a viable replanted fingertip (Fig. 3) [18,50]. Immediately following the injury, the amputated digit should be wrapped in sterile gauze soaked in normal saline, placed in a plastic bag, and then stored in a mix of ice and water as the patient is transported to the emergency department [10,55]. Amputated fingertips, due to their lack of muscular tissue, can stay viable for long periods of time: up to 6–12 h in cases of warm ischemia and 24–30 h in cases of cold ischemia [51–53]. Digital replantation is currently indicated for injuries involving the thumb, single digits distal to the insertion of the flexor digitorum superficialis tendon, and multiple digits [18,54]. A 2011 systematic review by Sebastin and Chung found a mean survival rate of 86% associated with 2273 distal digital replantations. No differences were found between zone I and II replantations, but successful repair of a vein and a clean-cut injuries were associated with better outcomes [13]. Contraindications for replantation include cases in which digits are severely damaged by crush or contamination mechanisms, the presence of peripheral vascular disease, and the presence of systemic diseases associated with vascular compromise [55]. While the scope of amputation cases that fall under the indications for replantation is vast, the operating surgeon must make his or her decision to proceed with the procedure based on the probability of a successful functional and cosmetic outcome [53]. Numerous factors have been found to influence this process. Digits that have undergone clean-cut amputation tend to have significantly better restorative outcomes than digits that have been crushed or avulsed [56]. Additionally, warm ischemia time of less
Fig. 3. Thump replantation procedure. Vascular anastomosis is crucial to the success of this figure. Not the digital artery (white arrow) intact proximally.
than 12 h, or cold ischemia time of less than 30 h, is associated with higher success rates [53]. Digital injuries in elderly patients, who are more likely to suffer from numerous systemic comorbidities that interfere with proper healing, and males, who may experience more severe injuries, tend to have lower success rates than those in younger and female patients, respectively [53,57]. While alcohol consumption does not appear to influence the success rate of digit replantation, smoking is associated with poorer results overall as nicotine is a well-known vasoconstrictor; in fact, the replanted digits of non-smokers have a survival rate that is 11.8 times higher than that of smokers [57]. Lastly, patients with atherosclerosis, autoimmune diseases, connective tissue diseases, and diabetes mellitus, all signs of potential vascular compromise, tend to be prone to poor results [53]. In cases of amputation, bone and tendon injuries should generally be repaired first. Following successful tendon repair, extensive arterial and venous repair is indicated as prior work has shown that overall replantation results are correlated with the number of vessels repaired. Digital nerve repair should be addressed last. Epineural sutures are generally sufficient for this process, but nerve grafts may be necessary [52]. Regardless of repair, cold intolerance and painful neuroma formation are potential sequela of digital nerve injury [10,26]. When replantation is not possible, composite grafting may be considered. In this procedure, the amputated tip is directly sutured to its parent finger after both ends have been thoroughly cleansed and debrided. While composite grafting has historically been used most frequently in young children, there is some evidence to
Fig. 2. A. Patient with multiple partial fingertip amputations following a lawn mower injury. B, C. The patients wounds were irrigate in the emergency department and revision amputation was performed to debride injured bone and soft tissue and to provide adequate soft tissue coverage.
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support its use in adults. However, by its nature, the indications for the use of composite grafting is limited to certain select cases of injury [3,18]. In those patients who cannot undergo composite grafting, wound closure by secondary intention or surgery may also be considered [3]. For defects smaller than 1.5 cm2 with no bone exposure, healing by secondary intention and surgical reconstruction appear to be equally efficacious in terms of healing and functional outcomes [27,42]. As a result, the vast majority of fingertip injuries are treated conservatively [41]. Treating fingertip amputations by secondary intention may involve the use of occlusive, semiocclusive and simple adherent sterile dressings, and subatmospheric wound therapy [58,59]. Semiocclusive dressing, in particular, has gained popularity in recent years. The wound is dressed after cleaning and debridement, and weekly wound cleaning and dressing changes are initiated. Patients are instructed to continue to use the affected hand as they normally would, without immobilization. Wound closure, accompanied by a recovery in sensation, occurs within 2–8 weeks [43]. While treatment with secondary intention is generally successful in indicated patients, care must be taken in patients with bone shortening, in which support for the nail is compromised. In these patients, in order to avoid the development of the hook nail deformity as the wound closes, care must be undertaken to excise the nail bed 2 mm proximal to the shortened bone [3,60]. In patients who cannot maintain an open wound for an extended period of time, skin grafts may be utilized. However, grafts do not necessarily always lead to favorable outcomes in all patients and may instead result in greater cold intolerance, compromised durability, and persistent tenderness [3,58].
Limitations of this literature review This review was limited to the management of fingertip injuries in adults. As such, it does not cover injuries of the hand more generally. Additionally, it does not include fingertip injuries in children, whose management can vary significantly from that of a more mature population. Moreover, this review covers only the most common techniques used to manage fingertip injuries that have been studied over time. Newer emerging, or experimental, techniques are not included. Conclusion Hand and finger injuries are not an uncommon occurrence in the United States, accounting for approximately 4.8 million visits to emergency departments each year [1]. Traumatic finger amputations of varying zones total approximately 45,000 cases annually [49]. Since the fingertip performs complex sensory and aesthetic functions, the proper management of these injuries is crucial. All fingertip injuries should be thoroughly cleaned and debrided. While both sharp and crush injuries may present unique challenges, physicians must ensure that patients with crush injuries are thoroughly examined for nail bed injuries and distal phalangeal fractures, as these can lead to significant long-term morbidity if left untreated. The precise treatment strategy, whether conservative or operative, primarily depends on the extent of the injury and must be determined on a case-by-case basis. Funding The authors have no financial disclosures or conflicts or competing interests to report.
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