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Nail relocation by nail flap in digital injuries
0007- I226/82iO28440?3
British Journal oj Plastic Surgery (19X2) 35, 53-Y CC!1982 The Trustees of British Association of Plastic Surgeons
Nail relocation B. V. KRISHNA Plastic
Surgery
$02.00
by nail flap in digital injuries
and A. D. PELLY
Unit, Prince
of Wales Hospital,
Sydney,
Australia
Summan/-In circumstances where the nail complex is intact and undamaged it may be wiser to relocate the nail as a flap based on its vascular supply rather than resort to pulp replacement procedures such as a cross-finger flap or similar techniques which leave a hyposensitive pulp and finger injuries this procedure is decidedly a “parrot-beak” deformity of the nail. In “acute” preferable to amputation through the head of the middle phalanx.
digital arteries converge in the pulp of the terminal segment to form an H-shaped or cruciate anastomosis; from the point of union one vessel arises on each side, passing laterally and then dorsally round the waist of the terminal phalanx to form dorsal arcades in the nail bed. As the vessel passes round the narrow waist of the bone it divides into two, one branch passing forwards to form the distal arcade which lies over ungual process: the other branch passing transversely across to form the proximal arcade in the subungual space (Figs. 1 and 2).
The function of the nail in man is to protect the delicate terminal phalanx and tip of the finger. It helps in the appreciation of fine touch, in picking up small objects and in scratching. Its functional and cosmetic significance justifies our efforts to adopt a conservative approach in treating the distal segment of damaged fingers. The vascular supply of the nail bed and terminal segment of the finger was studied in detail by Flint (1956) who described three vascular arcades on the dorsal aspect of the terminal segment of the finger. On the ventral surface both
6.
il2.
T.
M.
Fig. I Dorsal vascular supply to the nail complex and the finger tip. The dorsal and ends in the formation of the superficial arcade (after Flint 19561. 53
6.
branch
arises from the volar digital
artery
54
BRITISH
Each palmar digital artery gives a dorsal branch at the level of mid-shaft of the middle phalanx of the finger; the dorsal branch crosses the dorsum of the distal interphalangeal joint to form the superficial arcade (Flint, 1956). The significance of the dorsal branch arising from each digital artery was stressed by Mortimer Shaw (1971). The superficial arcade lies in the subcutaneous tissue on the dorsum of the distal phalanx just distal to the distal inter-phalangeal joint. From it, branches pass distally to enter the proximal arcade. Thus the proximal arcade receives blood not only from the distal segment but also from the middle segment of the finger. In this way the nail-bed has a double arterial supply, an observation that was found to be constant in all the hands examined by Flint (1956).
JOURNAL
OF PLASTIC
SURGERY
Because of the rich vascular anatomy of the nail-bed and matrix, one can safely raise the nailcomplex on the dorsal vascular arcades, relying mainly on the contribution from the dorsal digital artery to the superficial arcade. We report a patient in whom the nail complex was relocated proximally on this vascular pedicle.
Case report In April 1980 a man aged 30 caught his right hand in the fan-belt of a tractor. He sustained a severe crush injury which amputated the thumb through the metacarpo-phalangeal joint and caused irregular lacerations over the index and middle fingers. He was admitted to the Plastic Surgery Unit three months later with extensive scarring and loss of the pulp of the distal segment of the index finger. Both flexor tendons and the radial digital nerve had been damaged and there had been a compound fracture of the proximal phalanx (Figs. 3A, B). Because of the damage to the index finger it was decided to pollicise this digit. The distal segment was retained to be discarded at a second stage when an attempt would be made to relocate the nail. In August 1980, the nail-complex of the pollicised . D.A. index was raised with the dorsal periosteum of the
,
P.A.
P.N.F.-
-T.
-
Fig. 2 Dorsal Flint 1956).
vascular
arcades
from the dorsal
aspect
M.
(after
Fig. 3 (A B) Pre-operative view. Note the scarred pulp of the distal segment of the index finger. The nail is normal but is without any distal pulp support.
NAIL RELOCATION
BY NAIL FLAP
IN DIGITAL
INJURIES
distal phalanx as a flap based on the dorsal branch of the ulnar side volar digital artery. The distal segment of the pollicised index was amputated through the head of the middle phalanx giving a more natural length to the new thumb (Figs. 4B. C). Part of the dorsal skin of the flap (Fig. 4A) was de-epithelialised and the skin over the middle phalanx was minimally undermined. The nail flap was relocated well proximally over the middle phalanx to ensure skeletal support to the growing nail. Neuromata of the digital nerves on the radial aspect of the pollicised index and the middle fingers were excised and nerve grafting was performed. In view of the excellent carpo-metacarpal joint movements of the thumb no attempt was made to repair the flexor tendon in the new thumb. There was good blood flow in the nail flap on release of the tourniquet. Post-operatively recovery was uneventful (Figs. 5A, B) and six months later the nail was growing normally and required trimming (Fig. 6A. B).
55
(ii)
In patients with distal segment pulp loss due to pulp space infection complicated by extensive scarring. (iii) In patients with a painful, scarred and tender distal pulp successful relocation of the nail is an attractive alternative to amputation through the head of the middle phalanx and preserves the function of the nail.
Discussion
Nail relocation which was successful in our patient could be considered in the management of other surgical problems: (i)
Acute finger tip injuries with loss of most of the distal phalanx and pulp; relocation of the nail could provide nail support and avoid any “parrot beak deformity”.
C
Fig. 4 (A) The index finger has been pollicised. The area of skin to be de-epithelialised proximal to the nail matrix is cross-hatched. This will be tucked under the minimally undermined proximal skin.
Fig. 4 (B, C) Nail complex has been raised along with the periosteum of the terminal phalanx as a flap based on the dorsal digital vessels. De-epithelialised portion was tucked underneath the proximal skin after an appropriate skin excision had been carried out.
56
BRITISH
A Fig. 5
(A, B) The relocated
Fig. 6
(A, B) Six months
nail at the end of the operation.
A later there is good pulp and bony support
to the nail.
JOURNAL
OF PLASTIC
SURGERY
NAIL
RELOCATION
BY NAIL FLAP
IN DIGITAL
57
INJURIES
Acknowledgements We would like to thank the Medical Illustration Department of the Prince of Wales Hospital for their help with the illustrations, Mr M. H. Flint, FRCS and the Publishers for to reproduce Figures 1 and 2 which were permission published in this Journal (1956. 8, 186).
References Flint, M. H. (1956). Some observations on the vascular supply of the nail bed and terminal segments of the finger. British Journal of Plastic Surgery, 8, 186. Lewin, K. (1965). The normal finger nail. British Journal qf Dermatology. 77, 421. Shaw. M. H. (1971). Neurovascular island pedicle flaps for termmal dtgttal scars-a hazard. British Journul of Plastic Surgery. 24, 161.
O’Brien, B. McC. (1968). Neurovascular for terminal amputations and digital of Hastic Surgery. 21, 258.
island pcdicle flaps scars. British Journal
The Authors Mr B. V. Krishna, FRACS, Visiting Plastic Surgeon, Campbelltown Hospital, 2560 New South Wales. Australia. Mr A. D. PelIy, FRCS, FRACS, Consultant Plastic Surgeon, Plastic Surgery Unit, Prince of Wales Hospital. Sydney, Australia.
Requests for reprints to: Mr B. V. Krishna. FRACS, Visiting Plastic Surgeon, Campbelltown Hospital, 25600 New South Wales. Australia.
British Journal oj Plastic Surgery (19X2) 35, 53-Y CC!1982 The Trustees of British Association of Plastic Surgeons
Nail relocation B. V. KRISHNA Plastic
Surgery
$02.00
by nail flap in digital injuries
and A. D. PELLY
Unit, Prince
of Wales Hospital,
Sydney,
Australia
Summan/-In circumstances where the nail complex is intact and undamaged it may be wiser to relocate the nail as a flap based on its vascular supply rather than resort to pulp replacement procedures such as a cross-finger flap or similar techniques which leave a hyposensitive pulp and finger injuries this procedure is decidedly a “parrot-beak” deformity of the nail. In “acute” preferable to amputation through the head of the middle phalanx.
digital arteries converge in the pulp of the terminal segment to form an H-shaped or cruciate anastomosis; from the point of union one vessel arises on each side, passing laterally and then dorsally round the waist of the terminal phalanx to form dorsal arcades in the nail bed. As the vessel passes round the narrow waist of the bone it divides into two, one branch passing forwards to form the distal arcade which lies over ungual process: the other branch passing transversely across to form the proximal arcade in the subungual space (Figs. 1 and 2).
The function of the nail in man is to protect the delicate terminal phalanx and tip of the finger. It helps in the appreciation of fine touch, in picking up small objects and in scratching. Its functional and cosmetic significance justifies our efforts to adopt a conservative approach in treating the distal segment of damaged fingers. The vascular supply of the nail bed and terminal segment of the finger was studied in detail by Flint (1956) who described three vascular arcades on the dorsal aspect of the terminal segment of the finger. On the ventral surface both
6.
il2.
T.
M.
Fig. I Dorsal vascular supply to the nail complex and the finger tip. The dorsal and ends in the formation of the superficial arcade (after Flint 19561. 53
6.
branch
arises from the volar digital
artery
54
BRITISH
Each palmar digital artery gives a dorsal branch at the level of mid-shaft of the middle phalanx of the finger; the dorsal branch crosses the dorsum of the distal interphalangeal joint to form the superficial arcade (Flint, 1956). The significance of the dorsal branch arising from each digital artery was stressed by Mortimer Shaw (1971). The superficial arcade lies in the subcutaneous tissue on the dorsum of the distal phalanx just distal to the distal inter-phalangeal joint. From it, branches pass distally to enter the proximal arcade. Thus the proximal arcade receives blood not only from the distal segment but also from the middle segment of the finger. In this way the nail-bed has a double arterial supply, an observation that was found to be constant in all the hands examined by Flint (1956).
JOURNAL
OF PLASTIC
SURGERY
Because of the rich vascular anatomy of the nail-bed and matrix, one can safely raise the nailcomplex on the dorsal vascular arcades, relying mainly on the contribution from the dorsal digital artery to the superficial arcade. We report a patient in whom the nail complex was relocated proximally on this vascular pedicle.
Case report In April 1980 a man aged 30 caught his right hand in the fan-belt of a tractor. He sustained a severe crush injury which amputated the thumb through the metacarpo-phalangeal joint and caused irregular lacerations over the index and middle fingers. He was admitted to the Plastic Surgery Unit three months later with extensive scarring and loss of the pulp of the distal segment of the index finger. Both flexor tendons and the radial digital nerve had been damaged and there had been a compound fracture of the proximal phalanx (Figs. 3A, B). Because of the damage to the index finger it was decided to pollicise this digit. The distal segment was retained to be discarded at a second stage when an attempt would be made to relocate the nail. In August 1980, the nail-complex of the pollicised . D.A. index was raised with the dorsal periosteum of the
,
P.A.
P.N.F.-
-T.
-
Fig. 2 Dorsal Flint 1956).
vascular
arcades
from the dorsal
aspect
M.
(after
Fig. 3 (A B) Pre-operative view. Note the scarred pulp of the distal segment of the index finger. The nail is normal but is without any distal pulp support.
NAIL RELOCATION
BY NAIL FLAP
IN DIGITAL
INJURIES
distal phalanx as a flap based on the dorsal branch of the ulnar side volar digital artery. The distal segment of the pollicised index was amputated through the head of the middle phalanx giving a more natural length to the new thumb (Figs. 4B. C). Part of the dorsal skin of the flap (Fig. 4A) was de-epithelialised and the skin over the middle phalanx was minimally undermined. The nail flap was relocated well proximally over the middle phalanx to ensure skeletal support to the growing nail. Neuromata of the digital nerves on the radial aspect of the pollicised index and the middle fingers were excised and nerve grafting was performed. In view of the excellent carpo-metacarpal joint movements of the thumb no attempt was made to repair the flexor tendon in the new thumb. There was good blood flow in the nail flap on release of the tourniquet. Post-operatively recovery was uneventful (Figs. 5A, B) and six months later the nail was growing normally and required trimming (Fig. 6A. B).
55
(ii)
In patients with distal segment pulp loss due to pulp space infection complicated by extensive scarring. (iii) In patients with a painful, scarred and tender distal pulp successful relocation of the nail is an attractive alternative to amputation through the head of the middle phalanx and preserves the function of the nail.
Discussion
Nail relocation which was successful in our patient could be considered in the management of other surgical problems: (i)
Acute finger tip injuries with loss of most of the distal phalanx and pulp; relocation of the nail could provide nail support and avoid any “parrot beak deformity”.
C
Fig. 4 (A) The index finger has been pollicised. The area of skin to be de-epithelialised proximal to the nail matrix is cross-hatched. This will be tucked under the minimally undermined proximal skin.
Fig. 4 (B, C) Nail complex has been raised along with the periosteum of the terminal phalanx as a flap based on the dorsal digital vessels. De-epithelialised portion was tucked underneath the proximal skin after an appropriate skin excision had been carried out.
56
BRITISH
A Fig. 5
(A, B) The relocated
Fig. 6
(A, B) Six months
nail at the end of the operation.
A later there is good pulp and bony support
to the nail.
JOURNAL
OF PLASTIC
SURGERY
NAIL
RELOCATION
BY NAIL FLAP
IN DIGITAL
57
INJURIES
Acknowledgements We would like to thank the Medical Illustration Department of the Prince of Wales Hospital for their help with the illustrations, Mr M. H. Flint, FRCS and the Publishers for to reproduce Figures 1 and 2 which were permission published in this Journal (1956. 8, 186).
References Flint, M. H. (1956). Some observations on the vascular supply of the nail bed and terminal segments of the finger. British Journal of Plastic Surgery, 8, 186. Lewin, K. (1965). The normal finger nail. British Journal qf Dermatology. 77, 421. Shaw. M. H. (1971). Neurovascular island pedicle flaps for termmal dtgttal scars-a hazard. British Journul of Plastic Surgery. 24, 161.
O’Brien, B. McC. (1968). Neurovascular for terminal amputations and digital of Hastic Surgery. 21, 258.
island pcdicle flaps scars. British Journal
The Authors Mr B. V. Krishna, FRACS, Visiting Plastic Surgeon, Campbelltown Hospital, 2560 New South Wales. Australia. Mr A. D. PelIy, FRCS, FRACS, Consultant Plastic Surgeon, Plastic Surgery Unit, Prince of Wales Hospital. Sydney, Australia.
Requests for reprints to: Mr B. V. Krishna. FRACS, Visiting Plastic Surgeon, Campbelltown Hospital, 25600 New South Wales. Australia.