Fingertip injuries

Background: Fingertip injuries are extremely common. Out of the various available reconstructive options, one needs to select an option which achieves a painless fingertip with durable and sensate skin cover. The present analysis was conducted to evaluate the management and outcome of fingertip injuries. Materials and Methods: This is a retrospective study of 150 cases of fingertip Injuries of patients aged six to 65 years managed over a period of two years. Various reconstructive options were considered for the fingertip lesions greater than or equal to 1 cm2. The total duration of treatment varied from two to six weeks with follow-up from two months to one year. Results: The results showed preservation of finger length and contour, retention of sensation and healing without significant complication. Conclusion: The treatment needs to be individualized and all possible techniques of reconstruction must be known to achieve optimal recovery.

T he hand is prone to domestic and industrial trauma females (n=34) predominantly had kitchen or household with fingertips being the most frequently injured injuries. The males (n=102) were predominantly victims of portion of the hand. 1 Fingertip resurfacing is a work-related mishaps, the majority being agricultural and challenging reconstructive problem as the treatment varies industrial-related accidents. Crush injury (n=48) was found widely and is thus controversial. The goals of treatment to be the commonest cause of fingertip trauma, followed by are to maintain the length of the digit as well as to provide laceration (n=30) and avulsion injuries (n=16). well padded, stable and sensate yet pain-free skin. We retrospectively reviewed the management and outcome The injuries were evaluated in a careful and systematic of 150 cases of fingertip injuries managed over a period manner for finger involvement, crush versus sharp injuries, of two years. location, depth, angle of the defect, nail bed involvement and status of the remaining soft tissue, co-morbid conditions

MATERIALS AND METHODS
and the configuration of the fingertip defect. Standardized radiographs and photographs were also taken. A retrospective analysis of 150 cases of fingertip injuries treated by different methods over a period of two years was Various reconstructive options were considered based on undertaken. Fingertip injuries were defined as lesions greater the philosophy and techniques of earlier and contemporary than or equal to 1cm 2 in the terminal phalanx. A detailed surgeons [ Table 1]. In volarly directed wounds larger than . and tetanus immunization status was taken. The male predominance (M: F 90:60) was seen due to increased exposure and occupational hazards. The majority of the males were either agricultural or industrial workers. The age group involved was six to 65 years. The pediatric cases (n=14) predominantly were due to door crush injury. The (n=8) was preferred in skilled professionals like artists, computer professionals and technicians. Composite tip grafting (n=6) was usually considered in tip amputations in children below six to seven years of age. However, in one adult girl who was a computer professional it was attempted and was successful. When bone or tendon was found to be exposed, a local flap was considered. IJO -April -June 2007 / Volume 41 / Issue 2 considered for the wounds with volar and transverse avulsions with exposed bone with excess lateral skin. In the volarly directed wounds without sufficient pulp, cross-finger flap (n=19) was preferred [ Figures 3 and 4]. In oblique amputations,Venkataswami oblique flap was considered (n=10). The thenar flap (n=7) was preferred in females for transverse, volar and dorsal injuries involving the index and middle fingers. In elderly patients, patients with co-morbid conditions, and in unskilled laborers revision amputation was often considered.
Saraf S, et al.: Fingertip injuries amputations (n=25) and Mangling type of injuries (n=13) accounted for the remaining fingertip injuries. Middle finger (n=38) followed by multiple finger injuries (n=34) were found to be the most commonly involved. The thumb was found to be involved in 21 cases. The index (n=29), ring (n=18) and little finger (n=10) accounted for the remaining injuries. The majority of the injuries occurred at work. The majority of these injuries healed with excellent results in terms of maintenance of maximum finger length and minimization of cosmetic deformity and functional disability [ Table 1].
In thumb tip defects less then 1.5 cm, the Moberg flap (n=9) Postoperative follow-up was two months to one year. was preferred. In defects exceeding more then 1.5 cm first The observations were recorded for appearance, patient dorsal metacarpal artery flap/Littler flap/groin flap [Figures satisfaction, two-point discrimination, hypersensitivity 5 and 6] were primarily done. All the nail bed lacerations and cold intolerance, numbness, pain, active range of were repaired under loup magnification with 6-0/7-0 Vicryl. motion and active use. The evaluation was done for The nail was always reposited back as a splint to reduce the general appearance, use, sensations and static two-point subsequent nail deformities. discrimination employing 1 2 3 grading. The results were classified as good (10), fair (5-10) and poor (< 5) depending The total duration of treatment varied from two to six upon the total aggregate. For static two-point discrimination weeks. The patients were followed up from two months the scoring criteria was: 6mm or more: 1, 3 to 6 mm: 2 to one year. In follow-up, fingertips were reassessed and and 3 mm or less: 3. All the patients were found to achieve evaluated for length, padding, nail deformity, fingertip measurable average of 6mm two-point discrimination. sensation and range of motion, and were also photographed Nearly all the patients were satisfied with the functional in standardized views.
result and the aesthetic contour. The incisions healed with inconspicuous scars. The work incapacity time averaged between four to eight weeks and most patients could return to their routine.
Crush injury (n=48) was found to be the commonest type of fingertip trauma, followed by lacerated (n=30) and avulsion All flaps healed uneventfully, except for 10 patients in whom injuries (n=16). The clean cut amputations (n=18), Blunt cut marginal necrosis of the flap occurred, which was managed   conservatively. Partial wound dehiscence was observed in three patients. Partial wound detachment and infection was seen in three and two patients respectively. Cold intolerance was observed in seven and paresthesia in three patients. Joint stiffness was noted in three of the cases [ Table 1]. Evans and Bernadis (2000) proposed a new PNB (pulp, nail, bone) classification system for fingertip injuries. 5 This system classifies a fingertip injury into three areas: pulp, nail and the bone. As this classification system is new, more long-term studies will be required for its usefulness.

DISCUSSION
As fingertip injuries can be treated in different ways injury. 3,4 The injuries classified as Zone I occur distal to the depends on the orientation and configuration of the wound, distal phalanx with preservation of the majority of the nail injured digit and sex of the patient. If the wound is small and a relatively minor injury but their improper management their management needs to be carefully individualized. can lead to considerable loss of skilled hand function.
If there is no or minimal tissue loss, the wound can be Fingertip injuries lead to significant morbidity affecting closed primarily with or without debridement. Healing by the occupational as well social activities. They account for secondary intention or open technique by combination of approximately 10% of all accidents reported in the casualty wound contraction and re-epithelialization is applicable to and two-thirds of hand injuries in children.
small volarly directed fingertip wounds with no exposure of bone. 6-8 This is not preferred for wounds greater than 1 cm The management of fingertip injuries is complex and not as it takes a long time to heal with the loss of volume. This without controversy as a variety of treatment options are approach has a definite place for fingertip injuries in children available. Goals of treatment in fingertip injuries include as they have good capacity of regeneration. If the wound preservation of useful sensation, maximizing functional is larger than 1 cm and volarly directed, without exposure length, preventing joint contractures, providing satisfactory of bone or tendon, skin grafting provides faster healing. appearance and avoiding donor disfigurement and Split-thickness grafts are favored as contraction results in a functional loss. 2 smaller defect. However, some authors favor full-thickness grafts as they re-innervate early and provide durable The approach to the management of fingertip injuries coverage. 9-11 Composite tip grafts are often considered depends on many variables, including patient age, sex, for young children below the age of six years but are not hand dominance, profession, hobbies, finger involvement, reliable for adults. 12,13 When bone or tendon is exposed at location, depth, angle of the defect, nail bed involvement, the base of a fingertip wound, the use of skin grafts is not status of the remaining soft tissue, co-morbid conditions and feasible and a local flap is necessary. 3 the anatomy of the fingertip defect. 3 As the primary goal of treatment of an injury to the fingertip is a painless fingertip The type of flap reconstruction which is appropriate with durable and sensate skin, the knowledge of fingertip depends on the extent and configuration of the tip loss. Injuries classified as Zone II are located distal to the lunula of the nail bed and are characterized by the exposure of the distal phalanx. These injuries require flap for reconstruction. 3 The plane of Zone II can be further classified as dorsal, transverse or volar, according to the plane of the amputation. The slope of transection and the condition of the local tissue determine the best reconstructive technique.
Injuries classified as Zone III involve the nail matrix and involves a finger with a transverse amputation beyond the mid-nail level and dorsal oblique amputations beyond the proximal nail fold, the volar V-Y flap (Atasoy) gives good results. 14 Bilateral V-Y (Kutler) flaps are best applied to volar and transverse avulsions with exposed bone when excess lateral skin is present. 15 The cross-finger flap is preferable if the wound is volar-directed without sufficient volar pulp to facilitate V-Y flap. However, if local flap is not possible, a regional flap like thenar, cross-finger flap or neurovascular island flap may have to be considered. [16][17][18] The thenar flap can be used for volar, transverse and dorsal injuries, specially for index and long fingers and is often preferred

CONCLUSION
The critical evaluation of fingertip defect and various techniques is necessary to choose the best possible reconstructive option from esthetic and functional recovery [ Table 2]. Though the strict guidelines regarding management are difficult to formulate, the following recommendations are likely to be helpful in achieving a satisfactory functional and aesthetic result. In volarly directed wounds larger than 1cm without exposed bone or tendon, split-thickness graft systemic co-morbid conditions, revision amputations are is preferable. Full-thickness grafting may be preferred in skilled professionals. In children below six to seven years, composite tip grafting should be considered. If there is no Thumb tip defects need special consideration as preservation or minimal tissue loss, the wound can be closed primarily. of thumb length is always a priority for optimal hand Conservative management may be employed for fingertip function. The rectangular volar advancement (Moberg) is injuries less than 1 cm with no bone exposure. the preferred option for smaller defects less then 1.5 cm as it brings sensate durable skin to the thumb tip. 24 In thumb The flap should be considered whenever bone or tendon defects more then 1.5 cm first dorsal metacarpal artery is found to be exposed. The technical choice of flap is to flap or the Littler flap are often required for glabrous and be dictated by the anatomy of the tip loss. The volar V-Y sensate resurfacing with preservation of thumb length. 25 flaps may be preferred in dorsally angulated amputations Large thumb defects are often best reconstructed with beyond the proximal nail level and transverse amputations a free sensate flap from the great toe/first web space. 26 beyond the mid-nail level. Bilateral (Lateral) V-Y flaps may be Occasionally, a cross-finger flap from the dorsum of the considered for the wounds with slightly volar and transverse index finger is required if the Littler flap and first dorsal avulsions with exposed bone with excess lateral skin. In metacarpal artery flap are not available for sensate the volarly directed wounds without sufficient pulp, crossresurfacing of the thumb. As the dorsal vascular anatomy finger flap may be done. In obliquely directed amputations, is dependent on the proper digital vessels in digits, the oblique triangular flaps give satisfactory results. In females Moberg flap should not be used in the digits.
with transverse, volar and dorsal injuries, especially involving the index and middle fingers thenar flap may be preferred. Nail bed lacerations should be repaired preferably under In elderly patients, mentally unstable patients, osteoarthritic loupe magnification to prevent nail plate abnormalities. 27 patients, uncontrolled diabetics and in unskilled laborers Occasionally, large defects of the nail bed require splitrevision amputations can be considered. thickness graft from an uninjured area of nail bed or from the second toe. Occasionally, in some fingertip injuries In thumb tip defects less then 1.5 cm, the Moberg flap revision amputation is preferable to allow tension-free is preferable. In defects exceeding 1.5 cm first dorsal closure of the soft tissues and adequate padding in an effort to minimize recovery time and hasten return to  After tip reconstructive surgery, splintage of the involved finger for 2-3 weeks should be considered for early and safe