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Open treatment of fingertip injuries in adults
Open treatment of fingertip injuries in adults Ninety patients with 100 fingertip injuries of more than 1.0 cm 2 in area were treated by repeated dressing and a strict rehabilitation program. Healing time varied from 2 to 9 weeks. Although there was a 27% incidence of nail deformity, other complications such as amputation neuroma, painful stump, or stiffness of joints were extremely rare. This prospective study shows that the open method has a definite place in the treatment of certain fingertip injuries.
S. P. Chow, F.R.C.S.E., and E. Ho, M.B., B.S.(HK), Hong Kong
FingertiP injury is extremely common. 1 Various methods have been used to deal with it, including simple revision amputation,2 skin grafting,3 local flaps,4, 5, 6 and distant flaps. 7, 8, 9 However, in most developing countries this injury is so prevalent that it is frequently treated by the most junior intern or nursing officer in the Casualty Department. This results in a high incidence of complications such as hematoma formation, infection, and in later stages, painful stump, amputation neuroma, nail deformity, and many others. Many of these complications are due to bad technique and, in order to avoid this, we began in 1978, to treat fingertip injuries with a simple method of repeated dressing. This method is well accepted by children10 and in adults when the defect is small and confined to soft tissue. 11, 12 With a larger area, local flaps seem to be favored by most hand surgeons. After the initial pilot study we found the results of simple dressing so encouraging that in 1979 we started a prospective trial for fingertip injuries of more than 1.0 cm2 in area in adults.
Material and method All patients with terminal wounds of the finger distal to the proximal interphalangeal joint with a resultant defect of more than 1.0 cm2 in area were included in the study. Patients under 15 years of age were excluded. Those with associated tendon, nerve, bone, and vessel injuries were excluded because these injuries would interfere with the planned treatment program. On admission to the ward the involved digit was given a metacarpal block with 1% lidocaine (Xylocaine). The wound was then washed with aqueous From the Department of Orthopaedic Surgery, University of Hong Kong, Hong Kong. Received for publication June 3, 1981. Reprint requests: Dr. S. P. Chow, Department of Orthopaedic Surgery, University of Hong Kong, Hong Kong. Tel: 5-8192258
470
THE JOURNAL OF HAND SURGERY
Table I. Age distribution of the patients Age (years)
15-30 31-50 51-70
Na. afpatients (%) 34 33 23
(38) (37) (25)
chlorhexidine solution (1: 1,000 dilution) and a debridement was performed. Any protruding bone was nibbled until it was about 5 mm below the level of the soft tissue. The nail and the nail bed were left untouched. The wound was then dressed with framycetinimpregnated tulle gras. All the patients were taught elevation of the limb to minimize subsequent swelling in the hand. They were then discharged on the same day and prescribed a one-week course of antibiotics (ampicillin and cloxacillin). They were followed in the outpatient clinic three times a week and during each visit the dressings were taken off after adequate soaking in aqueous chlorhexidine. Active movement was encouraged in all joints during this process. This chlorhexidine bath treatment was enhanced by removal of any scab or debris overlying the stump because we felt that the scab would trap necrotic material or discharge and thereby delay healing. When the wounds were completely epithelialized the patients were sent to the occupational therapist for a 2-week course of stump skin-toughening exercises. Immediately after this the first functional assessment was performed. This included assessment of skin texture, abnormal sensibility, tenderness, neuroma pain, two-point discrimination in the fingertip, range of movement of the neighboring joints, cosmesis, and complications. The patients then went back to work. At 6 months the second assessment was performed. To compare the results of this study with results from patients treated by other methods we searched through
0363-5023/82/050470+07$00.70/0
© 1982 American Society for Surgery of the Hand
Vol. 7, No . 5 September 1982
Treatment of fing ertip injuries ill adults
471
11
5
LEFT
RIGHT
Fig. 1. Distribution of fingers involved.
25
I ~
w
AVERAGE: 27.3 DAYS
25
roo-
18
20
18
15
13
<.!)
13
z: u..
~
10
8
r--
4
1
2
3
4
5
6
7
~ 8
DURATION OF HEALING TIME IN WEEKS
9
10
11
12
~
Fig. 2. Distribution of healing time, i.e., the duration between injury and full epithelialization of the wound (as shown in Fig. 4).
the records of 100 previous fingertip injury patients treated before we started the open method. The healing time, duration of treatment, and complications were analyzed.
Results From March to August 1980, 125 consecutive cases of fingertip injury were admitted into this prospective trial. Thirty-five patients failed to appear for assess-
ment at 6 months and were excluded. This left 90 patients for analysis. Of these 90, 69 were men and 21 women . The age distribution is shown in Table I. The majority of injuries (88%) were caused from crushing by machinery. Sharp cutting injuries accounted for the rest (12%) . The dominant and nondominant hands were involved in an equal number of patients (45 each). Altogether 100 fingers were involved and their distribution is shown in Fig. 1. The healing
472
The Journal of HAND SURGERY
Chow and Ho
Fig. 3. Example of a typical wound on the day of injury.
Table II. Results of functional assessment
Skin texture Delicate Moderate Tough Sensibility Hyperesthesia Hypoesthesia Stump tenderness Amputation neuroma Two-point discrimination 2mm 4mm 6mm 8 mm :=.8mm Full range of movement
On going back to work (%)
At 6 months (%)
4 46 50
0 28 72
27 24 31 0
21 17 1 0
8 32 32 14 14 60
6 55 26 5 8 98
time varied from 9 to 59 days with an average of 27.3 days (Fig. 2). Figs. 3 and 4 show the appearance of a typical wound initially and after full epithelialization. The duration of total treatment is shown graphically in Fig. 5; it varied between 25 and 71 days, with an average of 41.5 days. The average permanent disability as assessed by the Labour Department was 1.96%, with a range of 0% to 6%. The results of the functional assessment on time before returning to work and at 6 months are summarized in Table II.
Fig. 4. The appearance of the same finger tip as in Fig. 3 at the time of full epithelialization 2.5 weeks later.
Table III. Complications of 100 fingertip injuries treated by open method (% affected) Early Infection Granuloma Bone protruding At 6 months Nail deformity (total) Beaking Splitting Shortening and narrowing Combined
27 6 3 15 3
It can be seen that pain is extremely rare. A consid-
erable number of patients had a subjective abnormal sensibility in the form of hyperesthesia or hypoesthesia, but this was never bothersome to the patients. Skin texture and two-point discrimination were satisfactory at 6 months and the range of movement as compared to the uninjured side was extremely good. Complications are shown in Table III. In one patient an infection occurred beneath an overlying scab and required drainage and one patient developed granuloma, which subsided after cauterization. One finger with bone protrusion required further nibbling of bone. By far the most significant complication was fingernail deformity. This took the form of shortening and narrowing (Fig. 6), beaking (Fig. 7), splitting (Fig. 8), or
Vol. 7, No . 5 September 1982
Treatment of fillgertip illjuries ill adults
25
473
AVERAGE: 41.5 DAYS
23 ~
(/)
~ w
15
15
r---
12 _ 13
-
f-
ex:
a...
~
10
10
10
6 ~
1
t--I 1
2
3
4
5
6
7
8
9
10
11
12
DURATION OF TOTAL TREATMENT IN WEEKS ------Fig. 5. Total loss of working days, i.e., duration from injury to conclusion of the skin-toughening program.
Fig. 7. Extreme beaking of nail as seen from the lateral aspect.
Fig. 6. Shortening and narrowing of finger nail.
combinations of these problems (Fig. 9). Out of 57 fingers with an initial fingernail injury, 20 eventually developed a normal nail. These were mostly injuries involving loss of less than the terminal third of nail. When loss of two thirds of the nail occurred, half of the fingers developed a beaking or a curved nail. This was usually seen in those associated with a sizeable pulp loss . When loss of nail occurred at the level of the lunula or more proximally, almost all fingers ended up with an extremely short and narrowed nail and a few
developed a slanting nail. Fragmented nail bed usually resulted in a normal nail, but when there was coexistent laceration of the eponychia, splitting nail usually developed. The results of 100 fingertip injuries in 82 patients treated by our interns and junior residents before the institution of the open method were analyzed retrospectively from the patients ' records. Again, those with tendon, nerve, bone, and vessel injuries were excluded. The various treatment methods included simple suturing in 6 fingers, revision amputation in 56, local V-Y flaps in 6, split thickness skin graft in 15, and full thickness skin graft in 17. These patients, like those in
474 Chow and Ho
The Journal of HAND SURGERY
Fig. 8. Split nail of the thumb.
Fig. 10. Appearance of an injured long finger with loss of a segment of 1.5 cm of the tip and also loss of an area of volar soft tissue . Total raw area is 2.0 em x 2.0 em.
epithelialization. 13. 14 The process of wound contraction allows the scar to migrate distally, leaving the cut ends of the digital nerves more proximally and thus explaining the scarcity of amputation neuroma. Wound contraction probably continues for some time during the healing phase . At 6 months most scars in Fig. 9. The fingernail showed a complex deformity consisting of beaking , splitting, spiking , and overlapping.
the present study, also received proper physiotherapy and occupational therapy treatment after operation. The average time for healing was 25 days and the average duration of treatment was 46 days. The number of complications shown in Table IV are appallingly high . This is perhaps due to the fact that most of the operations were performed by the interns on the wards. The average permanent disability as assessed by the Labour Department was 3.67%, with a range of 0.5% to 8%. Discussion
Healing of an open wound by repeated dressing probably works through both wound contraction and
our patients had fully contracted beneath the nail and were barely visible. In fact, the skin over the fingertip looked almost normal, with good sensibility and little discomfort (Figs . 10-13). Leaving the wound open has the advantage of allowing blood and discharge to come out and infection was seen only in one patient. Most of our patients (88%) had received crushing injuries . In such cases, when the viability of the skin may be doubtful, it is perhaps unwise to perform plastic flap surgery or even to suture the skin for fear of further jeopardizing the circulation. The wound becomes relatively pain free after a few days, unlike those in which stitches were used; stitches are often too tight and too close to the wound. Thus , active movement can be started by the patient early. In only two patients was the range of movement of the neighboring joints decreased.
Vol. 7, No.5 Treatment of fingertip injuries in adults
September 1982
475
Fig. 11. Same finger as Fig. 10, 8 months later.
Table IV. Complications of 100 fingertip injuries treated by other methods Early Hematoma formation Delayed wound healing Wound infection Failure of grafting or flaps Later Stiffness of neighboring joints Painful stump Amputation neuroma Posttraumatic sympathetic dystropy
6 20 17 8 8 8 7 2
Fig. 12. Another example of a big terminal loss with an area
2.5 em x 4.0 em.
}". }
~%
The most outstanding feature of this method of treatment is its simplicity; it requires minimal special skill. This is of vital importance in less \ developed countries where fingertip injuries are so prev~lent and yet are so frequently treated by the most junior staff of the hospital. In Hong Kong, before the institution of this method, fingertip injuries were treated in various ways including revision amputation, skin grafts, local flaps, and so on. The complication rate was extremely high (Table IV). These patients were reluctant to return to work for a long time after injury because of pain. The picture has been completely changed with use of the open method. At the end of this program, almost all patients volunteered to return to work. Thus, the apparently long duration of the program (average 41.5 days)
Fig. 13. Same finger as Fig. 12, 6 months later.
476
The Journal of HAND SURGERY
Chow alld Ho
in fact compares favorably with the time lost with other methods (average 46 days) previously used by our interns and junior residents. In the rare instances when the patient was not a laborer, he or she would in fact be allowed to go back to work in a few days, with the dressing on. The average permanent disability as assessed by the Labour Department was also less in the open dressing group (1.96%) compared to the operated group (3.67%), apparently because of less joint stiffness and pain. A strict comparison of the two groups of patients, however, is not valid because those in the present study will probably be under observation and control more during treatment. In experienced hands, however, primary surgery should hasten healing and the patient should be able to return to work in about 3 weeks. Although the duration of treatment matters little to our patients because they still receive two thirds of their salary after injury, in places under a different socioeconomic system this may be a major consideration. One major drawback of the open treatment is the high incidence (27%) of fingernail deformity. Although our patients are laborers in the great majority of cases and they do not mind the cosmetic result, we believe that some attention to the nail and nail bed during the initial debridement would help to lower the incidence of nail deformity. Thus, in cases of fragmented nail bed with laceration of eponychia, interposition of a silastic sheet may prevent split nail formation. In loss of nail more proximal than the lunula, when a shortened and narrowed nail is likely to form, nail ablation should be considered. However, it may be wiser to delay this procedure until later when the patient himself decides to have the ablation. Beaking is probably due to overhanging nail beds being drawn down by the contracting scar. Perhaps in cases when two thirds of the nail is lost (50% may develop beaking), one should make sure that the nail matrix is completely supported by bone and that the soft tissue is at least 5 mm longer than the nail remnant. In our patients, we have found that nibbling of the bone to 5 mm below the soft tissue usually prevents the complication of bone protrusion. Whether these procedures will be effective or not has to be answered by a separate prospective study on fingernail injuries. At this stage, we believe that the open method is most suitable for developing countries where experienced surgeons are not always available. It is especially indicated in crushing injuries and a good result can be anticipated when the injury is confined to soft tissues or involves only the distal third of the fingernail. Primary surgical coverage of the wound should be considered when the patient cannot afford the time for repeated dressing for socioeconomic reasons. It should also be
done in cases where associated injuries of the hand precludes the use of the open method. This includes injury to tendon, nerve, bone, or blood vessels that might require a special postoperative program of their own. In certain cases, when the likelihood of fingernail deformity is high (e.g., when loss of nail is more than two thirds) and is unacceptable to the patient, special surgical procedures will be indicated. 15 When preservation of length becomes of paramount importance and nibbling of bone is contraindicated, skin coverage of the tip will be required. Primary surgery will have a better result when the injury is due to a sharp cut and of course, when an experienced surgeon is available. We would like to thank the physiotherapists and occupational therapists of Queen Mary Hospital and David Trench Rehabilitation Centre, Hong Kong, for treating our patients and Mr. A. Ma of our research laboratory for helping with the functional assessment of our patients.
REFERENCES 1. Constant E: Finger tip injuries. R Med Trial Tech QB
17:273-85, 1971 2. Harvey FJ, Harvey PM: A critical review of the results of primary finger and thumb amputations. Hand 6: 157-62, 1974 3. Newmeyer WL, Kilgore ES Jr: Finger tip injuries-A simple effective method of treatment. J Trauma 14:5864, 1974 4. Atasoy E, Joakimidis E, Kasdan ML, Kutz JE, Kleinert HE: Reconstruction of the amputated finger tip with a triangular volar flap-A new surgical procedure. J Bone Joint Surg [Br] 52:921-6, 1970 5. Kutler W A: A new method for finger tip amputation. JAMA 133:29-30, 1947 6. Biddulph SL: The neurovascular flap in finger tip injuries. Hand 11:59-63, 1979 7. Miller AJ: Single finger tip injuries treated by thenar flap. Hand 6:311-4, 1974 8. Kleinert HE, McAlister CG, MacDonald CJ, Kutz JE: A critical evaluation of cross finger flaps. Trauma 15:75663, 1974 9. Moberg E: Aspects of sensation in reconstructive surgery ofthe upperlimb. J Bone JointSurg [Br] 46:817-25, 1964 10. Das SK, Brown HG: Management of lost finger tips in children. Hand 10:16-27, 1978 11. Holm A, Zachariae L: Finger tip lesions-An evaluation of conservative treatment versus free skin grafting. Acta Orthop Scand 45:382-92, 1974 12. Louis DS, Palmer AK, Burney RE: Open treatment of digital tip injuries. JAMA 244:697-8, 1980 13. Fox J, Golden G, Rode Neaver G et al: Nonoperative management of finger tip pulp amputation by occlusive dressing. Am J Surg 133:255-6, 1977 14. Walter JB: Wound healing. Otolaryngology 5: 171, 1976 15. Flatt AE: Nail-bed injuries. Br J Plast Surg 8:34-7, 1955
S. P. Chow, F.R.C.S.E., and E. Ho, M.B., B.S.(HK), Hong Kong
FingertiP injury is extremely common. 1 Various methods have been used to deal with it, including simple revision amputation,2 skin grafting,3 local flaps,4, 5, 6 and distant flaps. 7, 8, 9 However, in most developing countries this injury is so prevalent that it is frequently treated by the most junior intern or nursing officer in the Casualty Department. This results in a high incidence of complications such as hematoma formation, infection, and in later stages, painful stump, amputation neuroma, nail deformity, and many others. Many of these complications are due to bad technique and, in order to avoid this, we began in 1978, to treat fingertip injuries with a simple method of repeated dressing. This method is well accepted by children10 and in adults when the defect is small and confined to soft tissue. 11, 12 With a larger area, local flaps seem to be favored by most hand surgeons. After the initial pilot study we found the results of simple dressing so encouraging that in 1979 we started a prospective trial for fingertip injuries of more than 1.0 cm2 in area in adults.
Material and method All patients with terminal wounds of the finger distal to the proximal interphalangeal joint with a resultant defect of more than 1.0 cm2 in area were included in the study. Patients under 15 years of age were excluded. Those with associated tendon, nerve, bone, and vessel injuries were excluded because these injuries would interfere with the planned treatment program. On admission to the ward the involved digit was given a metacarpal block with 1% lidocaine (Xylocaine). The wound was then washed with aqueous From the Department of Orthopaedic Surgery, University of Hong Kong, Hong Kong. Received for publication June 3, 1981. Reprint requests: Dr. S. P. Chow, Department of Orthopaedic Surgery, University of Hong Kong, Hong Kong. Tel: 5-8192258
470
THE JOURNAL OF HAND SURGERY
Table I. Age distribution of the patients Age (years)
15-30 31-50 51-70
Na. afpatients (%) 34 33 23
(38) (37) (25)
chlorhexidine solution (1: 1,000 dilution) and a debridement was performed. Any protruding bone was nibbled until it was about 5 mm below the level of the soft tissue. The nail and the nail bed were left untouched. The wound was then dressed with framycetinimpregnated tulle gras. All the patients were taught elevation of the limb to minimize subsequent swelling in the hand. They were then discharged on the same day and prescribed a one-week course of antibiotics (ampicillin and cloxacillin). They were followed in the outpatient clinic three times a week and during each visit the dressings were taken off after adequate soaking in aqueous chlorhexidine. Active movement was encouraged in all joints during this process. This chlorhexidine bath treatment was enhanced by removal of any scab or debris overlying the stump because we felt that the scab would trap necrotic material or discharge and thereby delay healing. When the wounds were completely epithelialized the patients were sent to the occupational therapist for a 2-week course of stump skin-toughening exercises. Immediately after this the first functional assessment was performed. This included assessment of skin texture, abnormal sensibility, tenderness, neuroma pain, two-point discrimination in the fingertip, range of movement of the neighboring joints, cosmesis, and complications. The patients then went back to work. At 6 months the second assessment was performed. To compare the results of this study with results from patients treated by other methods we searched through
0363-5023/82/050470+07$00.70/0
© 1982 American Society for Surgery of the Hand
Vol. 7, No . 5 September 1982
Treatment of fing ertip injuries ill adults
471
11
5
LEFT
RIGHT
Fig. 1. Distribution of fingers involved.
25
I ~
w
AVERAGE: 27.3 DAYS
25
roo-
18
20
18
15
13
<.!)
13
z: u..
~
10
8
r--
4
1
2
3
4
5
6
7
~ 8
DURATION OF HEALING TIME IN WEEKS
9
10
11
12
~
Fig. 2. Distribution of healing time, i.e., the duration between injury and full epithelialization of the wound (as shown in Fig. 4).
the records of 100 previous fingertip injury patients treated before we started the open method. The healing time, duration of treatment, and complications were analyzed.
Results From March to August 1980, 125 consecutive cases of fingertip injury were admitted into this prospective trial. Thirty-five patients failed to appear for assess-
ment at 6 months and were excluded. This left 90 patients for analysis. Of these 90, 69 were men and 21 women . The age distribution is shown in Table I. The majority of injuries (88%) were caused from crushing by machinery. Sharp cutting injuries accounted for the rest (12%) . The dominant and nondominant hands were involved in an equal number of patients (45 each). Altogether 100 fingers were involved and their distribution is shown in Fig. 1. The healing
472
The Journal of HAND SURGERY
Chow and Ho
Fig. 3. Example of a typical wound on the day of injury.
Table II. Results of functional assessment
Skin texture Delicate Moderate Tough Sensibility Hyperesthesia Hypoesthesia Stump tenderness Amputation neuroma Two-point discrimination 2mm 4mm 6mm 8 mm :=.8mm Full range of movement
On going back to work (%)
At 6 months (%)
4 46 50
0 28 72
27 24 31 0
21 17 1 0
8 32 32 14 14 60
6 55 26 5 8 98
time varied from 9 to 59 days with an average of 27.3 days (Fig. 2). Figs. 3 and 4 show the appearance of a typical wound initially and after full epithelialization. The duration of total treatment is shown graphically in Fig. 5; it varied between 25 and 71 days, with an average of 41.5 days. The average permanent disability as assessed by the Labour Department was 1.96%, with a range of 0% to 6%. The results of the functional assessment on time before returning to work and at 6 months are summarized in Table II.
Fig. 4. The appearance of the same finger tip as in Fig. 3 at the time of full epithelialization 2.5 weeks later.
Table III. Complications of 100 fingertip injuries treated by open method (% affected) Early Infection Granuloma Bone protruding At 6 months Nail deformity (total) Beaking Splitting Shortening and narrowing Combined
27 6 3 15 3
It can be seen that pain is extremely rare. A consid-
erable number of patients had a subjective abnormal sensibility in the form of hyperesthesia or hypoesthesia, but this was never bothersome to the patients. Skin texture and two-point discrimination were satisfactory at 6 months and the range of movement as compared to the uninjured side was extremely good. Complications are shown in Table III. In one patient an infection occurred beneath an overlying scab and required drainage and one patient developed granuloma, which subsided after cauterization. One finger with bone protrusion required further nibbling of bone. By far the most significant complication was fingernail deformity. This took the form of shortening and narrowing (Fig. 6), beaking (Fig. 7), splitting (Fig. 8), or
Vol. 7, No . 5 September 1982
Treatment of fillgertip illjuries ill adults
25
473
AVERAGE: 41.5 DAYS
23 ~
(/)
~ w
15
15
r---
12 _ 13
-
f-
ex:
a...
~
10
10
10
6 ~
1
t--I 1
2
3
4
5
6
7
8
9
10
11
12
DURATION OF TOTAL TREATMENT IN WEEKS ------Fig. 5. Total loss of working days, i.e., duration from injury to conclusion of the skin-toughening program.
Fig. 7. Extreme beaking of nail as seen from the lateral aspect.
Fig. 6. Shortening and narrowing of finger nail.
combinations of these problems (Fig. 9). Out of 57 fingers with an initial fingernail injury, 20 eventually developed a normal nail. These were mostly injuries involving loss of less than the terminal third of nail. When loss of two thirds of the nail occurred, half of the fingers developed a beaking or a curved nail. This was usually seen in those associated with a sizeable pulp loss . When loss of nail occurred at the level of the lunula or more proximally, almost all fingers ended up with an extremely short and narrowed nail and a few
developed a slanting nail. Fragmented nail bed usually resulted in a normal nail, but when there was coexistent laceration of the eponychia, splitting nail usually developed. The results of 100 fingertip injuries in 82 patients treated by our interns and junior residents before the institution of the open method were analyzed retrospectively from the patients ' records. Again, those with tendon, nerve, bone, and vessel injuries were excluded. The various treatment methods included simple suturing in 6 fingers, revision amputation in 56, local V-Y flaps in 6, split thickness skin graft in 15, and full thickness skin graft in 17. These patients, like those in
474 Chow and Ho
The Journal of HAND SURGERY
Fig. 8. Split nail of the thumb.
Fig. 10. Appearance of an injured long finger with loss of a segment of 1.5 cm of the tip and also loss of an area of volar soft tissue . Total raw area is 2.0 em x 2.0 em.
epithelialization. 13. 14 The process of wound contraction allows the scar to migrate distally, leaving the cut ends of the digital nerves more proximally and thus explaining the scarcity of amputation neuroma. Wound contraction probably continues for some time during the healing phase . At 6 months most scars in Fig. 9. The fingernail showed a complex deformity consisting of beaking , splitting, spiking , and overlapping.
the present study, also received proper physiotherapy and occupational therapy treatment after operation. The average time for healing was 25 days and the average duration of treatment was 46 days. The number of complications shown in Table IV are appallingly high . This is perhaps due to the fact that most of the operations were performed by the interns on the wards. The average permanent disability as assessed by the Labour Department was 3.67%, with a range of 0.5% to 8%. Discussion
Healing of an open wound by repeated dressing probably works through both wound contraction and
our patients had fully contracted beneath the nail and were barely visible. In fact, the skin over the fingertip looked almost normal, with good sensibility and little discomfort (Figs . 10-13). Leaving the wound open has the advantage of allowing blood and discharge to come out and infection was seen only in one patient. Most of our patients (88%) had received crushing injuries . In such cases, when the viability of the skin may be doubtful, it is perhaps unwise to perform plastic flap surgery or even to suture the skin for fear of further jeopardizing the circulation. The wound becomes relatively pain free after a few days, unlike those in which stitches were used; stitches are often too tight and too close to the wound. Thus , active movement can be started by the patient early. In only two patients was the range of movement of the neighboring joints decreased.
Vol. 7, No.5 Treatment of fingertip injuries in adults
September 1982
475
Fig. 11. Same finger as Fig. 10, 8 months later.
Table IV. Complications of 100 fingertip injuries treated by other methods Early Hematoma formation Delayed wound healing Wound infection Failure of grafting or flaps Later Stiffness of neighboring joints Painful stump Amputation neuroma Posttraumatic sympathetic dystropy
6 20 17 8 8 8 7 2
Fig. 12. Another example of a big terminal loss with an area
2.5 em x 4.0 em.
}". }
~%
The most outstanding feature of this method of treatment is its simplicity; it requires minimal special skill. This is of vital importance in less \ developed countries where fingertip injuries are so prev~lent and yet are so frequently treated by the most junior staff of the hospital. In Hong Kong, before the institution of this method, fingertip injuries were treated in various ways including revision amputation, skin grafts, local flaps, and so on. The complication rate was extremely high (Table IV). These patients were reluctant to return to work for a long time after injury because of pain. The picture has been completely changed with use of the open method. At the end of this program, almost all patients volunteered to return to work. Thus, the apparently long duration of the program (average 41.5 days)
Fig. 13. Same finger as Fig. 12, 6 months later.
476
The Journal of HAND SURGERY
Chow alld Ho
in fact compares favorably with the time lost with other methods (average 46 days) previously used by our interns and junior residents. In the rare instances when the patient was not a laborer, he or she would in fact be allowed to go back to work in a few days, with the dressing on. The average permanent disability as assessed by the Labour Department was also less in the open dressing group (1.96%) compared to the operated group (3.67%), apparently because of less joint stiffness and pain. A strict comparison of the two groups of patients, however, is not valid because those in the present study will probably be under observation and control more during treatment. In experienced hands, however, primary surgery should hasten healing and the patient should be able to return to work in about 3 weeks. Although the duration of treatment matters little to our patients because they still receive two thirds of their salary after injury, in places under a different socioeconomic system this may be a major consideration. One major drawback of the open treatment is the high incidence (27%) of fingernail deformity. Although our patients are laborers in the great majority of cases and they do not mind the cosmetic result, we believe that some attention to the nail and nail bed during the initial debridement would help to lower the incidence of nail deformity. Thus, in cases of fragmented nail bed with laceration of eponychia, interposition of a silastic sheet may prevent split nail formation. In loss of nail more proximal than the lunula, when a shortened and narrowed nail is likely to form, nail ablation should be considered. However, it may be wiser to delay this procedure until later when the patient himself decides to have the ablation. Beaking is probably due to overhanging nail beds being drawn down by the contracting scar. Perhaps in cases when two thirds of the nail is lost (50% may develop beaking), one should make sure that the nail matrix is completely supported by bone and that the soft tissue is at least 5 mm longer than the nail remnant. In our patients, we have found that nibbling of the bone to 5 mm below the soft tissue usually prevents the complication of bone protrusion. Whether these procedures will be effective or not has to be answered by a separate prospective study on fingernail injuries. At this stage, we believe that the open method is most suitable for developing countries where experienced surgeons are not always available. It is especially indicated in crushing injuries and a good result can be anticipated when the injury is confined to soft tissues or involves only the distal third of the fingernail. Primary surgical coverage of the wound should be considered when the patient cannot afford the time for repeated dressing for socioeconomic reasons. It should also be
done in cases where associated injuries of the hand precludes the use of the open method. This includes injury to tendon, nerve, bone, or blood vessels that might require a special postoperative program of their own. In certain cases, when the likelihood of fingernail deformity is high (e.g., when loss of nail is more than two thirds) and is unacceptable to the patient, special surgical procedures will be indicated. 15 When preservation of length becomes of paramount importance and nibbling of bone is contraindicated, skin coverage of the tip will be required. Primary surgery will have a better result when the injury is due to a sharp cut and of course, when an experienced surgeon is available. We would like to thank the physiotherapists and occupational therapists of Queen Mary Hospital and David Trench Rehabilitation Centre, Hong Kong, for treating our patients and Mr. A. Ma of our research laboratory for helping with the functional assessment of our patients.
REFERENCES 1. Constant E: Finger tip injuries. R Med Trial Tech QB
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