Fingertip Amputations and Vascular Flashcards
A 45-year-old man who is employed as a construction worker comes to the office because of pain in the small and ring fingers of the nondominant left hand. He says the pain worsens and the fingers become blotchy on exposure to cold. He has smoked one pack of cigarettes daily for 30 years. Examination shows subungual hemorrhages in the small finger and a digital brachial index of 0.4. Arteriography shows segmental occlusion of the ulnar artery at the wrist. Which of the following is the most appropriate management of this patient’s condition?
(A)Administration of a calcium channel blocker
(B)Intraarterial thrombolysis/fibrinolysis
(C)Resection and reconstruction of segmental ulnar artery
(D)Smoking cessation
(E)Stellate ganglion block
(C)Resection and reconstruction of segmental ulnar artery
Hypothenar hammer syndrome (HHS) describes digital ischemic symptoms secondary to either occlusion or aneurysmal dilation of the ulnar artery adjacent to the hamate. Although typically related to activities that involve repetitive trauma (eg, use of vibrating tools) to the palm, evidence exists to suggest that the condition arises in vessels with preexisting abnormalities, even in the absence of trauma.
Hypothenar hammer syndrome
Hypothenar hammer syndrome (HHS) describes digital ischemic symptoms secondary to either occlusion or aneurysmal dilation of the ulnar artery adjacent to the hamate. Although typically related to activities that involve repetitive trauma (eg, use of vibrating tools) to the palm, evidence exists to suggest that the condition arises in vessels with preexisting abnormalities, even in the absence of trauma.
When can calcium channel blockers be considered primary intervention for digital ischemia?
Calcium channel blockers and sympathetic blockade may alleviate vasospastic responses. These interventions may be combined with surgical therapy and can be considered as primary interventions in patients with less symptomatic hands and a digital brachial index less than 0.7.
A 22-year-old man comes to the emergency department 30 minutes after he sustained an amputation injury to the tip of the little finger of the left hand while using a circular saw. The patient was unable to locate the amputated part. Physical examination shows amputation of the tip of the finger at a level distal to the insertion of the profundus. The distal phalanx is exposed and protruding. Which of the following surgical interventions is most appropriate to preserve the grip strength of the hand?
A) Excision of the profundus tendon
B) Healing by secondary intention
C) Local flap coverage
D) Revision to the middle phalanx head
E) Suturing of the profundus tendon to the extensor tendon
C) Local flap coverage
Local flap coverage is indicated when there is exposed bone or tendon. The flexor profundus tendon attaches to the base of the distal phalanx. Loss of the profundus tendon results in a significant loss of grip strength. Therefore, the profundus should be preserved if possible. Wounds on the fingertip that are smaller than 1 cm are allowed to heal by secondary intention, which provides better return of sensation and an even smaller scarred area. Larger areas, particularly those with an exposed distal phalanx, require coverage. Skin grafting may be indicated for large wounds that are not expected to heal in a reasonable amount of time. The profundus tendon should not be sutured to the extensor tendon, because this could result in a quadriga effect and a loss of grip strength.
The flexor profundus tendon attaches to:
The flexor profundus tendon attaches to the base of the distal phalanx.
Why preserve the profundus tendon? (Esp relevant to ring and small fingers)
Loss of the profundus tendon results in a significant loss of grip strength. Therefore, the profundus should be preserved if possible.
Management of fingertip injuries <1 cm
Wounds on the fingertip that are smaller than 1 cm are allowed to heal by secondary intention, which provides better return of sensation and an even smaller scarred area.
Skin grafting may be indicated for large wounds that are not expected to heal in a reasonable amount of time.
A 53-year-old tire mechanic comes to the office because of a 6-month history of a painful mass on the ulnar side of the palm, cold intolerance in the ring and little fingers, and numbness of the little finger of the right hand. Physical examination shows an ulcer on the tip of the little finger. Range of motion of the fingers is full. Doppler signals in the superficial palmar arch disappear with radial artery occlusion. Which of the following is the most likely diagnosis? A) Fracture of the hook of the hamate B) Ganglion cyst of the Guyon canal C) Hypothenar hammer syndrome D) Persistent median artery E) Systemic sclerosis (scleroderma)
C) Hypothenar hammer syndrome
Hypothenar hammer syndrome occurs following repetitive blunt trauma to the hypothenar eminence. It is associated with cold intolerance, pain near the distal aspect of the Guyon canal, ulnar sensory dysfunction, and sometimes a mass near the hypothenar eminence. In severe cases, ulceration can occur in the ring and little fingers. The underlying pathology is thrombosis of the ulnar artery at the level of the Guyon canal.Surgical treatment of hypothenar hammer syndrome consists of excision of the thrombosed arterial segment, usually followed by vascular reconstruction with primary repair or construction of a vein graft.Fracture of the hook of the hamate, or hamulus, is seen more often in athletes who use rackets (ie, golfers, hockey players) or have direct trauma to the palm (ie, baseball catchers). An injury with acute pain is often noted, and tendon rupture may follow months later. Masses and ingertip ulceration are not seen with this condition. Treatment consists of excision of the fracture fragment.Ganglion cysts of the Guyon canal usually present with motor dysfunction, sensory dysfunction, or both. Cold intolerance, fingertip ulceration, and a mass are not usually found.Persistent median artery may present as a cause of carpal tunnel syndrome but would not cause a mass or ulceration.Systemic sclerosis is a relatively rare connective tissue disorder. Its hallmark is calcium deposits within the skin and progressive skin tightening. While skin ulcerations are found in systemic sclerosis, masses in the ulnar palm are not.
Hypothenar hammer syndrome: Clinical presentation
Hypothenar hammer syndrome occurs following repetitive blunt trauma to the hypothenar eminence. It is associated with cold intolerance, pain near the distal aspect of the Guyon canal, ulnar sensory dysfunction, and sometimes a mass near the hypothenar eminence
Hypothenar hammer syndrome: Severe cases
In severe cases, ulceration can occur in the ring and little fingers.
Hypothenar hammer syndrome: Surgical management
Surgical treatment of hypothenar hammer syndrome consists of excision of the thrombosed arterial segment, usually followed by vascular reconstruction with primary repair or construction of a vein graft.
Patient population who present with fracture of the hook of the hammate
Fracture of the hook of the hamate, or hamulus, is seen more often in athletes who use rackets (ie, golfers, hockey players) or have direct trauma to the palm (ie, baseball catchers).
Clinical history of fracture of hook of the hamate
An injury with acute pain is often noted, and tendon rupture may follow months later.
Management of fracture of the hook of the hamate
Treatment consists of excision of the fracture fragment.
Underlying pathology of hypothenar hammer syndrome
The underlying pathology is thrombosis of the ulnar artery at the level of the Guyon canal.
A 28-year-old man comes to the office 8 weeks after sustaining an amputation of the tip of the index finger that healed by secondary intention and has resulted in a hook nail deformity. Physical examination shows the residual nail growing over the residual tip of the finger. Which of the following is the most likely cause of this patient’s current condition?
A) Dorsal-sided tissue loss with loss of eponychial fold
B) Dorsal-sided tissue loss with loss of germinal matrix
C) Lateral-sided soft-tissue loss with ingrown nail fold
D) Volar-sided tissue loss with the nail bed folding over the residual tip
E) Volar-sided tissue loss with nail bed overgrowth by eponychial fold
D) Volar-sided tissue loss with the nail bed folding over the residual tip
The nail is supported by the dorsal tuft of the terminal phalanx. Following distal fingertip trauma, varying amounts of nail support may be lost, resulting in the nail curving palmarwards. This curvature is dependent on the degree of bony loss, the amount of remaining nail bed, and the degree of scar contracture at the hyponychial-pulp interface. The ?parrot beak,? or hook nail, deformity is caused most commonly by tight closure of a fingertip amputation and excessive palmar tension at the hyponychial-pulp suture line.The hook nail deformity is a relatively common complication following fingertip amputation. It can be corrected or prevented with a carefully performed surgical procedure. The nail plate is removed. The redundant nail bed that is folded over the tip of the terminal phalanx is carefully removed with an additional 2 mm that is supported by the terminal phalanx, which ensures that wound healing will not draw the nail bed over the tip of the phalanx again. The fingertip is then resurfaced by a V-Y advancement flap, with precautions taken to avoid all tension in the flap.
The nail is supported by:
The nail is supported by the dorsal tuft of the terminal phalanx.
Abnormal finger curvature after distal finger trip trauma
Following distal fingertip trauma, varying amounts of nail support may be lost, resulting in the nail curving palmarwards. This curvature is dependent on the degree of bony loss, the amount of remaining nail bed, and the degree of scar contracture at the hyponychial-pulp interface.
“Parrot beak,” or hook nail deformity
The “parrot beak,” or hook nail, deformity is caused most commonly by tight closure of a fingertip amputation and excessive palmar tension at the hyponychial-pulp suture line. It can be corrected or prevented with a carefully performed surgical procedure.
Correction of a “parrot beak,” or hook nail deformity
The nail plate is removed. The redundant nail bed that is folded over the tip of the terminal phalanx is carefully removed with an additional 2 mm that is supported by the terminal phalanx, which ensures that wound healing will not draw the nail bed over the tip of the phalanx again. The fingertip is then resurfaced by a V-Y advancement flap, with precautions taken to avoid all tension in the flap.
A 12-year-old boy is brought to the emergency department because of persistent pain and bruising under the fingernail of his left index finger 6 hours after sustaining a crush injury. Physical examination shows a subungual hematoma that is contained to a portion distal to the lunula. The surrounding nail plate is adherent and intact. The nail plate is not torn or lifted. Which of the following is the most appropriate management?
A) Amputation
B) Digital block with epinephrine
C) Elevation
D) Nail plate removal and sterile matrix graft
E) Trephination
E) Trephination
The treatment of nail injuries can vary depending upon whether or not a nail plate injury is noted. When the nail plate is intact, the diagnosis of a nail bed injury is determined by the presence of a subungual hematoma. Subungual hematomas cause pressure in the closed space between the nail plate and nail bed, resulting frequently in throbbing pain. Hematoma drainage (trephination) is required for pain relief. This can be done with a battery-powered microcautery device or heated sterile paper clip. The hole should be large enough to allow for prolonged drainage. Care should be taken with the cautery device to avoid further injury to the nail bed.If the nail edges are disrupted or the nail plate is torn, the nail plate should be removed to explore and repair the nail bed. The torn nail plate can be removed to provide exposure for the repair. Lifting the nail plate can sometimes further injure the nail bed. Complete removal is not always mandatory.Extremity elevation will only alleviate the pain minimally. A digital block with epinephrine will provide temporary relief. Amputation is excessive treatment for a nailbed hematoma.Nail beds that are missing a sterile matrix can be reconstructed with a sterile matrix graft, often from the same injured nail bed (smaller defect) or the great toe (larger defect).
How to decide on treatment of nail injuries?
The treatment of nail injuries can vary depending upon whether or not a nail plate injury is noted.
Diagnosis of nail bed injury when the nail plate is intact
When the nail plate is intact, the diagnosis of a nail bed injury is determined by the presence of a subungual hematoma.
Subungual hematoma
Subungual hematomas cause pressure in the closed space between the nail plate and nail bed, resulting frequently in throbbing pain.
Management of subungual hematoma
Hematoma drainage (trephination) is required for pain relief. This can be done with a battery-powered microcautery device or heated sterile paper clip. The hole should be large enough to allow for prolonged drainage.
If the nail edges are disrupted or the nail plate is torn: Management
If the nail edges are disrupted or the nail plate is torn, the nail plate should be removed to explore and repair the nail bed. The torn nail plate can be removed to provide exposure for the repair. Lifting the nail plate can sometimes further injure the nail bed. Complete removal is not always mandatory.
Nail beds that are missing a sterile matrix: Management
Nail beds that are missing a sterile matrix can be reconstructed with a sterile matrix graft, often from the same injured nail bed (smaller defect) or the great toe (larger defect).
A 55-year-old woman comes to the office because of a 3-month history of severe pain and stiffness after undergoing tendon repair to correct a laceration to the extensor digitorum communis in Zone VI of the long finger of the nondominant hand. Which of the following additional clinical findings is most likely to support a diagnosis of complex regional pain syndrome? A) Adhesion B) Disrupted tendon repair C) Normal blood flow D) Numbness E) Osteopenia
E) Osteopenia
Osteopenia is related to disuse and is typical in Stage II of complex regional pain syndrome (CRPS). The clinical presentation of CRPS is slightly different depending on the stage. Tendon adhesions and disruption of the tendon repair are not unique features of CRPS and occur regardless as complications of tendon repair surgery. Abnormalities in blood flow are common in CRPS, which is a direct effect of autonomic dysfunction, and occurs in 98% of cases. The vasomotor changes include loss of thermoregulatory and sudomotor control and manifest as a discolored limb (pale, red, or blue) with excessive sweating or anhidrosis.
Complex regional pain syndrome: Calcium stores need to be depleted by ___% for ostopenia to become apparent
Calcium stores need to be depleted by 30 to 50% for the osteopenia to become apparent, so this finding may appear more regularly in postmenopausal women.
The demineralization of ostopenia affects:
The demineralization affects both cortical and cancellous bone.
Complex regional pain syndrome: Stage I
In Stage I, there is extreme pain out of proportion to the injury, hyperesthesia, edema, erythema, and hyperhidrosis, all of which last for 3 months.
Complex regional pain syndrome: Stage II
Stage II is the ‘dystrophic’ phase and spans between the third and the ninth month. It is characterized by pain, pronounced stiffness, hard edema, altered blood flow (increased warmth alternating with cyanosis), hair loss, decreased moisture, and osteopenia visible on plain x-ray study.
Complex regional pain syndrome: Stage III
Stage III starts at approximately the ninth month and lasts until 18 months after onset. It represents the ‘atrophic’ phase, which features increased stiffness and pale, cool, and dry skin, but decreased pain.
Complex regional pain syndrome: Abnormalities in blood flow, which is a direct effect of __________, occurs in ___% of cases.
Abnormalities in blood flow are common in CRPS, which is a direct effect of autonomic dysfunction, and occurs in 98% of cases.
A 43-year-old woman comes to the emergency department after sustaining an amputation at the fingertip of the long finger of the dominant hand while attempting to unclog a snowblower. Physical examination shows pulp loss of 1 × 1.2 cm. Which of the following is the most appropriate method of reconstruction to maximize sensation and function?
A) Cross-finger flap from the ring finger
B) Full-thickness skin graft harvested from the hypothenar eminence
C) Full-thickness skin graft harvested from the medial elbow
D) Moist dressing changes until healing is complete
E) V-Y advancement flap
D) Moist dressing changes until healing is complete
Injuries to the fingertip are among the most common injuries seen by the hand and plastic surgeons. These injuries can affect all components of the hand, including skin, bones, nerves, tendons, and vessels. In fingertip injuries without a bony amputation or with minimum exposed bone (less than 0.5 mm), a variety of reconstruction methods are possible. For preservation of sensation of the fingertip, the most appropriate method of reconstruction is healing by secondary intention with the use of moist dressings.
Skin grafts, either full-or split-thickness, have the poorest sensory recovery. Flaps, either local or regional, provide decreased sensation in the reconstruction
For preservation of sensation of the fingertip in injuries <1 cm, the most appropriate method of reconstruction is:
For preservation of sensation of the fingertip, the most appropriate method of reconstruction is healing by secondary intention with the use of moist dressings.
For preservation of sensation of the fingertip in injuries <1 cm, methods which regain the LEAST sensation:
Skin grafts, either full-or split-thickness, have the poorest sensory recovery.
A 36-year-old executive comes to the office because of an 8-year history of cold intolerance and ulcers on the tips of the index and long fingers bilaterally. The patient is a nonsmoker. Physical examination shows thin fingers with shiny skin. Which of the following is the most likely diagnosis? A ) Buerger disease B ) CREST syndrome C ) Hyperthyroidism D ) Hypothenar hammer syndrome E ) Sickle cell anemia
B ) CREST syndrome
The set of symptoms in the patient described are consistent with scleroderma or systemic sclerosis. Findings in these patients include calcinosis, Raynaud phenomenon, esophageal dysphasia, sclerodactyly, and telangiectasia, or CREST syndrome. Those with overlap syndrome have associated findings characteristic of lupus, dermatomyositis, or rheumatoid arthritis. Therefore, CREST syndrome is the most likely diagnosis.
Findings in CREST syndroms
Findings in these patients include calcinosis, Raynaud phenomenon, esophageal dysphasia, sclerodactyly, and telangiectasia, or CREST syndrome. Those with overlap syndrome have associated findings characteristic of lupus, dermatomyositis, or rheumatoid arthritis.
Buerger disease and hand manifestations
Thromboangiitis obliterans: ulcers usually limited to hands and feet; A history of heavy smoking is more consistent with finger ulcers associated with thromboangiitis obliterans (Buerger disease)
A 42-year-old man sustains an avulsion injury to the index finger of the left hand after it is caught in a piece of machinery. He says he needs to return to his job as a manual laborer as soon as possible. The bone of the proximal phalanx is exposed. The avulsed segment of the finger includes the distal and middle phalanges andsoft tissue to the level of the mid-proximal phalanx, along with segments of tendons, nerves, and vessels. Which of the following is the most appropriate management?
A ) Coverage with a groin flap
B ) Coverage with a reverse radial forearm flap
C ) Microvascular replantation
D ) Revision amputation
E ) Skin grafting
D ) Revision amputation
For the patient described, the tendons, nerves, and vessels have been stretched and avulsed, which results in an extensive zone of injury.
A well-planned amputation should be considered a reconstructive procedure and can return functional use of the hand to the patient.
Amputation can result in a reliable and functional outcome and allow the patient to return to work quickly. Completion of the amputation can be performed, or ray amputation can be undertaken, to eliminate the intervening index finger segment and improve thumb pinch function.
Skin grafting is not likely to be successful in this patient, who has exposed bone. The lack of tendons would result in absence of movement, and the lack of nerves would lead to loss of sensibility.
A 36-year-old man comes for evaluation because he is dissatisfied with the appearance of his nail (synechia of the nail bed at the lateral aspect of the eponychial fold) after burning his hand. After removal of the nail, it is clear that more than one third of the nail bed is involved. Which of the following procedures is most likely to improve the appearance of the nail?
A ) Debridement of the nail bed and full-thickness skin grafting
B ) Dermabrasion of the nail bed and placement of a silicone rubber stent
C ) Excision of the scar tissue, reconstruction with an eponychial flap, and nail bed graft from a toe
D ) Reconstruction with a cross-finger flap to the distal pad and bone graft to the distal phalanx
E ) Resection of the scar, elevation of the nail bed for advancement, and primary repair of the nail bed
C ) Excision of the scar tissue, reconstruction with an eponychial flap, and nail bed graft from a toe
Nail bed deformities are common after injury to the fingertip. The photograph shows that the patient has a synechia of the nail bed at the lateral aspect of the eponychial fold. In the scenario described, the problem is twofold. First, the eponychial fold is contracted and adherent to the underlying nail bed. Second, the nail bed itself is likely scarred. Therefore, dermabrasion and stent will not affect the status of the nail bed and will not improve the deformity. Reconstruction with a cross-finger flap and bone graft is good for a hook nail deformity but is not appropriate for scarred nail bed. Excision of the scar and attempt at advancement and primary closure is likely to fail in the scenario described as it is limited to defect of 1 mm or less. Given these constraints, resection of the scar and replacement with a graft from an adjacent finger or from one of the toes along with a flap procedure on the eponychial fold is most likely to correct the deformity. Full-thickness skin grafting will not affect this patient’s goal of improved appearance.
A 43-year-old woman is brought to the emergency department after sustaining an injury to the right thumb and index finger from an ink press. Physical examination shows amputation of the right thumb at the carpometacarpal joint, and amputation of the index finger at the head of the middle phalanx. The amputated thumb was wrapped in a moist gauze towel immediately after the injury and appears to be severely mangled. Which of the following is the definitive management of the thumb? A ) Debridement and closure of wounds B ) Great toe-to-thumb transfer C ) Osteoplastic thumb reconstruction D ) Replantation of the thumb E ) Residual index finger pollicization
E ) Residual index finger pollicization
The thumb contributes roughly 40% to hand function, and the fingers contribute 60% to hand function. Therefore, amputation of the thumb decreases hand function up to 40%, making reconstruction a high priority.
If the index finger is injured and has little mobility, the injured index finger should be used for thumb reconstruction and serve as a stable post.
If thenar muscles are intact, opposition can be expected. Benefits of index finger transfer include aesthetic results, potential motion of transferred and retained joints, and provision of reliable sensation.
Debridement and closure of wounds is not ideal, as this would impair function of the dominant hand.
Great toe-to-thumb microsurgical reconstruction is best for amputations between the metacarpophalangeal (MCP) joint and interphalangeal joints but can be used for amputations proximal to the MCP. In the patient described, the traumatized index finger serves as an excellent alternative for reconstruction of the amputated thumb with preservation of a normal foot.
Contribution of the thumb vs fingers to hand function
The thumb contributes roughly 40% to hand function, and the fingers contribute 60% to hand function.
What is pollicization?
Pollicization refers to the neurovascular pedicle movement of a finger, often with its metacarpal, for thumb reconstruction.
When can pollicization be performed?
Pollicization can be used for amputations of the thumb between the middle of the first metacarpal and at the carpometacarpal joint, but it works best for amputation at the level of the carpometacarpal joint.
Benefits of index finger pollicization
Benefits of index finger transfer include aesthetic results, potential motion of transferred and retained joints, and provision of reliable sensation.
Great toe to thumb microsurgical reconstruction of the thumb is best when:
Great toe-to-thumb microsurgical reconstruction is best for amputations between the metacarpophalangeal (MCP) joint and interphalangeal joints but can be used for amputations proximal to the MCP.
Osteoplastic thumb reconstruction
Osteoplastic thumb reconstruction is rarely performed today, as it results in a stiff, broad, floppy thumb with limited sensation. It involves the combination of a bone graft and flap to lengthen the thumb.
During coverage of a defect with a reverse cross-finger flap, which of the following is the most appropriate location for application of a full-thickness skin graft?
A ) Dorsal surface of the middle phalanx of the donor finger
B ) Dorsal surface of the middle phalanx of the recipient finger
C ) Volar surface of the distal phalanx of the donor finger
D ) Volar surface of the distal phalanx of the recipient finger
E ) Volar surface of the middle phalanx of the donor finger
B ) Dorsal surface of the middle phalanx of the recipient finger
A reverse cross-finger flap is used to cover soft-tissue defects on the dorsum of an adjacent digit:
The skin on the donor finger is incised on the side closest to the recipient finger and elevated off of the underlying dorsal subcutaneous tissue. The dorsal subcutaneous tissue of the donor finger is raised as a flap based on the side closest to the recipient finger. The flap is sutured to the recipient finger and is used as a bed to receive a full-thickness skin graft. The native skin is then returned to the dorsum of the middle phalanx of the donor finger.
Reverse cross finger flap
A reverse cross-finger flap is used to cover soft-tissue defects on the dorsum of an adjacent digit.
Reverse cross finger flap procedure
The skin on the donor finger is incised on the side closest to the recipient finger and elevated off of the underlying dorsal subcutaneous tissue. The dorsal subcutaneous tissue of the donor finger is raised as a flap based on the side closest to the recipient finger. The flap is sutured to the recipient finger and is used as a bed to receive a full-thickness skin graft. The native skin is then returned to the dorsum of the middle phalanx of the donor finger.
Standard cross finger flap
If the volar surface of a finger requires coverage, a standard (not reverse) cross-finger flap is used.
Local flaps - covering the dorsal versus volar surface of a finger
Volar: Standard cross-finger flap
Dorsal: Reverse cross-finger flap
A 34-year-old man who works as a pipe fitter sustains amputation of the radial three digits of the nondominant left hand. Replantation of the thumb and long finger is performed. Three weeks later, the replanted thumb becomes necrotic. Photographs are shown (Necrotic thumb at the MCPJ, index thumb at the PIP). Which of the following methods of reconstruction is most likely to provide the best functional outcome?
A ) Amputation and web space deepening
B ) Debridement and coverage with a radial forearm flap
C ) Distraction lengthening of the remaining thumb
D ) Pollicization of the long finger
E ) Toe-to-thumb transfer
E ) Toe-to-thumb transfer
Toe-to-thumb transfer has become the standard of care for thumb reconstruction when the level of loss occurs at or around the metacarpophalangeal (MCP) joint. The functional outcomes from the transfer are excellent and the donor defect, while not completely free from morbidity, is acceptable. Wound and nerve complications, such as neuroma, can be successfully managed through traditional techniques.Revision amputation of the thumb in the patient described would be at or proximal to the MCP joint level. Even with web space deepening, there would be insufficient length of the thumb against which the other fingers could oppose.Distraction lengthening requires a higher-quality skin envelope than exists in the patient described to tolerate the increased space that would be occupied by the thumb metacarpal. In addition, the only remaining mobile joint in this patient would be the carpometacarpal (CMC) joint. Also, the distal end of a thumb created by this technique would have poor sensation and poor durability.
Debridement and coverage with a radial forearm flap would provide high-quality tissue that could even be made sensate with coaptation of the medial and lateral antebrachial cutaneous nerves to the digital nerve stumps. However, there would still be inadequate length of the thumb with this method.
Pollicization, while less commonly used in adult than in pediatric reconstruction, can still be useful when the level of amputation occurs at the CMC joint, or when the patient cannot tolerate or will not accept microsurgical transfer of a toe. Pollicization generally moves the index finger to the thumb position; pollicizing the long finger is technically very difficult to do because of the vascular pedicle. Given that the index finger is already lost in this patient, sacrifice of the long finger would leave only twomobile fingers on this hand.
Standard of care for thumb reconstruction when the level of loss occurs at or around the metacarpophalangeal (MCP) joint:
Toe-to-thumb transfer has become the standard of care for thumb reconstruction when the level of loss occurs at or around the metacarpophalangeal (MCP) joint.
Distraction lengthening requires a higher-quality skin envelope than exists in the patient described to tolerate the increased space that would be occupied by the thumb metacarpal. In addition, the only remaining mobile joint in this patient would be the carpometacarpal (CMC) joint. Also, the distal end of a thumb created by this technique would have poor sensation and poor durability.
Debridement and coverage with a radial forearm flap would provide high-quality tissue that could even be made sensate with coaptation of the medial and lateral antebrachial cutaneous nerves to the digital nerve stumps. However, there would still be inadequate length of the thumb with this method.
Pollicization, while less commonly used in adult than in pediatric reconstruction, can still be useful when the level of amputation occurs at the CMC joint, or when the patient cannot tolerate or will not accept microsurgical transfer of a toe. Pollicization generally moves the index finger to the thumb position; pollicizing the long finger is technically very difficult to do because of the vascular pedicle. Given that the index finger is already lost in this patient, sacrifice of the long finger would leave only two mobile fingers on this hand.
Why not perform revision amputation of the thumb at or proximal to the MCP joint level?
Even with web space deepening, there would be insufficient length of the thumb against which the other fingers could oppose.
When to perform pollicization versus toe-to-thumb transfer
Pollicization can be useful when the level of amputation occurs at the CMC joint, or when the patient cannot tolerate or will not accept microsurgical transfer of a toe.
Toe-to-thumb transfer has become the standard of care for thumb reconstruction when the level of loss occurs at or around the metacarpophalangeal (MCP) joint.
A 25-year-old woman is brought to the emergency department after sustaining an avulsion of the ring finger of the left hand. The avulsed part was transported to the hospital in a plastic bag. The patient is employed as a concert pianist and her livelihood depends on successful replantation. Which of the following is the most appropriate treatment to improve survival of the finger and optimize the clinical outcome?
A ) Acute bone grafting
B ) Coverage of the exposed tendons with a groin flap
C ) Delayed tendon reconstruction
D ) Neural repair with at least eight interrupted 10-0 nylon sutures
E ) Resection of the injured vessels and vein grafting
E ) Resection of the injured vessels and vein grafting
Ring avulsion injury remains one of the most challenging replantation problems because of the large zone of injury of the soft tissues. As a result, the regional vessels are significantly damaged due to the stretch avulsion, and as such, need to be resected widely and replaced with vein grafts.
Amputated parts should be transported dry in a saline-iced slurry and protected by a plastic bag. Bone grafting should be reserved for a failed union, in the subacute or late setting, while tendon repair should be performed at the time of replantation. A neural repair with more than four sutures is not necessary and may contribute to neuroma formation.
Management of digital vessels after significant stretch avulsion
Wide resection and replacement with bone grafts
A neural repair with more than _____ sutures is not necessary and may contribute to:
A neural repair with more than four sutures is not necessary and may contribute to neuroma formation.
A 47-year-old woman is brought to the emergency department immediately after sustaining a laceration of the left thumb while cutting pastrami with an industrial meat slicer. Physical examination shows loss of skin and subcutaneous tissue on the volar aspect of the thumb from the metacarpophalangeal joint flexion crease to the interphalangeal joint flexion crease. The flexor tendon and digital neurovascular bundles are exposed in the wound base. Perfusion and sensation of the tip of the thumb are intact. Which of the following is the most appropriate management?
A ) Full-thickness skin grafting
B ) Reconstruction with a first dorsal metacarpal artery flap
C ) Reconstruction with a thenar flap
D ) Reconstruction with a volar advancement (Moberg) flap
E ) Split-thickness skin grafting
B ) Reconstruction with a first dorsal metacarpal artery flap
The tissue requirements are determined by the nature of the wound bed and functional requirements for the site of reconstruction. Skin grafts are inappropriate in the face of exposed tendon or tendon sheath. Advancement of the volar tissue of the thumb is useful for distal thumb defects. Dissection of the skin, subcutaneous tissue, and neurovascular bundles from the underlying tissue and flexion of the interphalangeal joint allow for distal movement of the tissue for thumb pulp pad coverage. This approach would not be useful for a volar defect at the level of the proximal phalanx. The first dorsal metacarpal artery flap could be used to provide coverage of this area of the thumb. The skin and subcutaneous tissue can be elevated from the dorsum of the index finger to the level of the middle phalanx. The first dorsal metacarpal artery is included with this tissue. If a sensory flap is desired, branches of the radial nerve within the flap can be preserved or coapted to sensory nerves at the recipient site. A thenar flap would be appropriate for providing coverage for fingertips but not this region of the thumb.
Advancement of the volar tissue of the thumb is useful for:
Advancement of the volar tissue of the thumb is useful for distal thumb defects.
First dorsal metacarpal artery flap
The skin and subcutaneous tissue can be elevated from the dorsum of the index finger to the level of the middle phalanx. The first dorsal metacarpal artery is included with this tissue. If a sensory flap is desired, branches of the radial nerve within the flap can be preserved or coapted to sensory nerves at the recipient site.
Replantation is most likely to be contraindicated in which of the following patients who have sustained amputations of a single digit at the level of the interphalangeal joint?
A ) A 5-year-old girl with an amputation through the index finger
B ) A 25-year-old steelworker with an amputation through the index finger
C ) A 30-year-old musician with an amputation through the long finger
D ) A 35-year-old attorney with an amputation through the long finger
E ) A 40-year-old construction worker with an amputation through the thumb
B ) A 25-year-old steelworker with an amputation through the index finger
Functional outcomes following replantation vary with the level of injury. Replantation of single digits amputated within the zone II level is relatively contraindicated due to postoperative stiffness. It is also contraindicated when rehabilitation will significantly delay the patient’s return to work and the procedure offers minimal or no functional benefit. Replantation of single digits, particularly index fingers, usually does not improve hand function. Replantation should be considered on nearly all parts in healthy children. Replantation should be considered in most cases of thumb amputation.
Replantation of single digits amputated within the zone II level
Replantation of single digits amputated within the zone II level is relatively contraindicated due to postoperative stiffness.
General rule: When should pediatric finger amputation be considered?
Replantation should be considered on nearly all parts in healthy children.
General rule: When should thumb replantation be considered?
Replantation should be considered in most cases of thumb amputation.
Replantation of single digits vs hand function
Replantation of single digits, particularly index fingers, usually does not improve hand function.
Occupation vs finger replantation
It is contraindicated when rehabilitation will significantly delay the patient’s return to work and the procedure offers minimal or no functional benefit.
A 52-year-old man comes to the emergency department because he has increasing pain and swelling of the right index finger six hours after sustaining an injury to the tip of the finger. He says he was holding a small object in his nondominant hand to paint it with a high-pressure gun when he missed the object and injected oil-based paint into the tip of the index finger. On examination of the finger, sensation is intact and capillary refill is good. Which of the following is the most appropriate initial management?
A ) Amputation of the index finger
B ) Debridement of the index finger and serial dressing changes
C ) Elevation of the hand, administration of antibiotics, and early mobilization
D ) Incision and cleansing of the underlying tissue with sterile mineral oil
E ) Observation with serial examinations
B ) Debridement of the index finger and serial dressing changes
The patient described has a high-pressure injection injury to the index finger of his assisting hand. This situation warrants early aggressive surgical therapy. Outcome for delayed treatment is nearly uniformly poor, resulting in either amputation or permanent stiffness. The best outcomes result from emergent debridement of all involved tissue and open dressing changes. Early mobilization will assist in treatment.
As his finger remains perfused and sensate, there is no need for immediate amputation. Immediate amputation is appropriate for patients who present with cool, insensate fingers. Delayed amputation may be required for finger necrosis. Mineral oil is itself a hydrocarbon and potentially toxic and therefore not appropriate for the clinical scenario described.
The outcome for less caustic injection injury, such as water or air, is more favorable and therefore warrants less aggressive therapy. These patients can be treated with administration of antibiotics, elevation, and early mobilization with minimal or no debridement. Because the patient described had oil-based paint injected into his finger, the less aggressive therapy is not appropriate.
High-pressure chemical injection injury to the finger: What results in increased morbidity.
The chemicals tend to travel down the finger and can involve the tendon sheaths with migration to the wrist, resulting in increased morbidity.
High-pressure chemical injection injury to the finger: Subcutaneous tissue
The subcutaneous tissue is destroyed by either saponification or dissolution of the lipids.
High-pressure chemical injection injury to the finger: Management
This situation warrants early aggressive surgical therapy. Outcome for delayed treatment is nearly uniformly poor, resulting in either amputation or permanent stiffness. The best outcomes result from emergent debridement of all involved tissue and open dressing changes. Early mobilization will assist in treatment.
Management of less caustic substances after high pressure injection injury
The outcome for less caustic injection injury, such as water or air, is more favorable and therefore warrants less aggressive therapy. These patients can be treated with administration of antibiotics, elevation, and early mobilization with minimal or no debridement.
A 37-year-old woman who is a professional cellist sustains a laceration with soft-tissue loss of the tip of the long finger of the dominant right hand. The wound heals by second intention. One year later, the patient reports that the loss of soft tissue on the fingertip prevents her from working. Physical examination shows thin adherence to the underlying bone. The full length of bone is preserved, and active and passive motion is within normal limits. Sensation is decreased in the area of scarring. Reconstruction with which of the following flaps is most likely to provide thenbest improvement in soft-tissue bulk and sensation? A ) Cross-finger B ) Groin C ) Kutler (lateral advancement) D ) Thenar E ) Toe pulp
E ) Toe pulp
A number of options exist for the management of soft-tissue loss from the volar aspect of the fingertip. Healing by second intention can provide a durable fingertip with acceptable sensation. Unfortunately, when there is significant soft-tissue loss, there may be insufficient padding for the fingertip. The goal of intervention is to improve the bulk of the soft tissue with sensate tissue if possible.
Thenar and groin flaps involve staged transfer of soft tissue to the recipient digit. These flaps supply the desired soft-tissue bulk; however, they do not provide sensation to the transferred tissue. A cross-finger flap would supply a small amount of additional soft-tissue bulk. The flap is innervated through coaptation of dorsal digital nerves of the donor site to recipient digital nerves. Neither the sensation nor the amount of soft-tissue bulk would match that provided by the toe pulp flap. The Kutler flap entails advancement of tissue from the sides of the finger over the tip in V to Y fashion. Sensation and vascularity are maintained for this tissue. The amount of tissue that this technique provides would be modest compared to the other approaches.
Management of post traumatic soft tissue loss of a finger tipe
The toe pulp flap
Toe flap pulp
The flap is harvested from the lateral aspect of the first toe or the medial aspect of the second toe. T
Toe flap pulp vascular supply
The vascular supply of the flap is the first dorsal metatarsal artery and branches of the saphenous venous system.
Toe flap pulp innervation
The flap is innervated by the deep peroneal nerve and the palmar digital nerves of the toe. These nerves can be coapted to nerves of the recipient finger.
Toe flap pulp: Two-point discrimination
Two-point discrimination of less than 10 mm can be obtained.
Kutler flap
The Kutler flap entails advancement of tissue from the sides of the finger over the tip in V to Y fashion. Sensation and vascularity are maintained for this tissue. The amount of tissue that this technique provides is modest.
A 9-year-old girl is brought to the office two years after she sustained a crush injury to the nail bed of her left ring finger. Her mother says that the nail grows but then lifts off the finger and catches onto her clothes. The patient complains that the nail looks ugly. On examination, the germinal matrix is intact but 95% of the sterile matrix is scarred. Which of the following is the most appropriate treatment?
A ) Coverage with lateral Kutler flaps
B ) Full-thickness nail bed grafting from the long finger
C ) Lateral paronychial-releasing incisions with central advancement flap
D ) Release of the sterile matrix scar and acellular dermal matrix grafting
E ) Split-thickness nail bed grafting from the great toe
E ) Split-thickness nail bed grafting from the great toe
The sterile matrix is the distal portion of the nail bed and adds a thin layer of cells to the undersurface of the nail, which maintains nail adherence to the nail bed. In the patient described, the sterile matrix is scarred and the nail cannot adhere to the nail bed. Reconstruction requires removal of the scarring to the sterile matrix followed by split-thickness nail bed grafting. Though harvesting of a split-thickness nail bed graft should not leave any deformity, one study found a 25% donor deformity.
Where is the germinal matrix located?
The germinal matrix is the most proximal part of the nail bed and is hidden from view by the eponychium.
Function of the germinal matrix
The germinal matrix produces 90% of the nail plate and extends to the visible white arc of the nail known as the lunula.
Sterile matrix
The sterile matrix is the distal portion of the nail bed and adds a thin layer of cells to the undersurface of the nail, which maintains nail adherence to the nail bed.
Why is a scarred sterile matrix an issue?
When the sterile matrix is scarred, the nail cannot adhere to the nail bed.
Reconstruction of a scarred sterile matrix
Reconstruction requires removal of the scarring to the sterile matrix followed by split-thickness nail bed grafting. Though harvesting of a split-thickness nail bed graft should not leave any deformity, one study found a 25% donor deformity.
Reconstruction of the germinal matrix
When using a nail bed graft for reconstruction of the germinal matrix, a full-thickness graft is needed. Also, when harvesting a full-thickness nail bed graft, donor morbidity will always occur.
Reconstruction of the sterile matrix versus the germinal matrix
Sterile matrix: Split thickness graft
Germinal matrix: Full thickness graft
Donor for reconstruction of nail bed (sterile matrix or germinal matrix) defects
The donor site should be from the first or second toes or from spare parts in multidigit injuries.
When can lateral paronychial-releasing incisions with central advancement flaps be used?
Lateral paronychial-releasing incisions with central advancement flap can be used for full-thickness germinal and sterile matrix losses up to around 4 mm
When is release of the sterile matrix scar and acellular regenerative dermal matrix grafting appropriate?
Release of the sterile matrix scar and acellular regenerative dermal matrix grafting are more appropriate for a pincer nail deformity.
A 35-year-old woman is brought to the emergency department four hours after sustaining an amputation of the right thumb when it was caught in a machine at a meatpacking plant. The amputated part (proximal phalanx, avulsed tendons) was wrapped in moist saline gauze and placed on ice within 20 minutes of the injury. Which of the following factors is most likely to limit the success of replantation of the thumb? A ) Inadequate bone stock B ) Initial treatment of digit C ) Mechanism of injury D ) Possibility of infection E ) Warm ischemia time
C ) Mechanism of injury
The extensor tendons and flexor tendons in the scenario described have been avulsed from the musculotendinous junction. In addition, the nerve ends extend proximally beyond the level of the soft-tissue injury; both of these findings are indicative of an avulsion-type injury. Such injury mechanisms often result in significant intimal injury within digital arteries, limiting the success of replantation. The amputated part was appropriately managed, and warm ischemia time was minimized. Digits have been successfully replanted with greater than 24 hours of cold ischemia time. Amputations at the metacarpophalangeal or interphalangeal level of the thumb may result in joint fusion; however, in this scenario, bone stock is adequate for skeletal fixation. Infection is a potential problem following any traumatic hand injury, but adequate surgical debridement and appropriate antibiotic coverage make replantation loss from infection a rare occurrence.
Avulsion injuries vs digital arteries
Such injury mechanisms often result in significant intimal injury within digital arteries, limiting the success of replantation. The amputated part was appropriately managed, and warm ischemia time was minimized. Digits have been successfully replanted with greater than 24 hours of cold ischemia time.
A 54-year-old man comes to the office because he has a two-year history of difficulty straightening the small finger of the dominant right hand. He reports that the finger “catches” when he puts on gloves or reaches into his pockets. He has no history of serious illness. Physical examination shows firm cords extending along the palmar surface of the small finger axis and the ulnar border of the proximal phalanx. Flexion contracture of the metacarpophalangeal (MCP) joint is 30 degrees, and flexion contracture of the proximal interphalangeal (PIP) joint is 65 degrees. Palmar/digital fasciectomy with complete correction of the PIP joint contracture is planned. Which of the following best describes the long-term outcome of both joints?
MCP // PIP A) Good // Good B) Good // Poor C) Poor // Good D) Poor // Poor
B) Good // Poor
Treatment of the PIP joint flexion contracture in Dupuytren disease can be difficult and often unsatisfying because early (within one to three years) partial recurrence is common. Adding to this frustration is the failure of recurrent PIP joint disease to respond to therapy and splinting as effectively as MCP joint recurrences.Primary treatment of PIP joint Dupuytren contractures often results in incomplete correction; this also stands in contrast to the complete correction typically obtained at the MCP joint.Recurrent PIP joint disease may require more aggressive management, including more extensive joint release (accessory collateral ligaments, palmar plate/check rein ligaments, flexor sheath) and possible dermatofasciectomy with full-thickness skin graft reconstruction. Outcomes from reoperation are guarded, and arthrodesis of the PIP joint as a salvage procedure may be warranted.Routine release of the volar/palmar plate has not been shown to improve outcomes for primary correction of PIP joint contractures in Dupuytren disease.
Correction of PIP vs MCP contracture with Dupuytren disease
MCP: Good
PIP: Poor
Primary treatment of PIP joint Dupuytren contractures often results in ________ correction
Primary treatment of PIP joint Dupuytren contractures often results in incomplete correction
Treatment of recurrent of PIP joint vs MCP joint Dupuytren contractures
Recurrent PIP joint disease responds to therapy and splinting less effectively than MCP joint recurrences.
When is arthrodesis indicated for PIP joint Dupuytren disease
Outcomes from reoperation are guarded, and arthrodesis of the PIP joint as a salvage procedure may be warranted.
A 47-year-old woman is brought to the emergency department 30 minutes after sustaining an amputation injury to the dominant right hand. The amputated part was wrapped in a wet towel immediately after the injury and has been kept on ice since that time. Physical examination shows a guillotine-type amputation of the hand at the distal aspect of the palm with minimal injury proximal and distal to the amputation. A photograph is shown (distal aspect of the palm). Which of the following structures is expected to have the poorest recovery following successful replantation? (A)Extensor digitorum communis (B)First dorsal interosseous (C)Flexor digitorum profundus (D)Flexor digitorum superficialis (E)Flexor pollicis brevis
(B)First dorsal interosseous
The first dorsal interosseous is in the zone of injury. When amputations occur through the distal aspect of the palm, the intrinsic muscles are usually injured and intrinsic function is poor despite successful replantation. Finger abduction and adduction, metacarpophalangeal joint flexion, and proximal and distal interphalangeal joint extension and key pinch are limited as a result. Debridement of injured muscle is recommended to prevent contracture and intrinsic tightness. In this setting, movement is generated by extrinsic muscle groups without the fine-tuning of motion usually provided by the intrinsic muscles.
What is injured / turn out the worst with amputation through the distal aspect of the palm?
When amputations occur through the distal aspect of the palm, the intrinsic muscles are usually injured and intrinsic function is poor despite successful replantation.
What is turns out okay with amputation through the distal aspect of the palm?
With sharp lacerations at the level of the distal palm, the flexor digitorum profundus and superficialis and extensor digitorum communis tendons typically function well with good repair technique, appropriate rehabilitation, and occasional secondary surgery.
What is limited as a result of injury to the intrinsics in the distal aspect of the palm?
Finger abduction and adduction, metacarpophalangeal joint flexion, and proximal and distal interphalangeal joint extension and key pinch are limited as a result.
Sharp versus blunt and avulsion injuries
Sharp injuries have the most discrete area of damage and therefore tend to have greater recovery of function.
Blunt and avulsion-type mechanisms, which have greater zones of injury, require more extensive reconstruction and are associated with less complete restoration of function, including motion and sensibility.
A 55-year-old man who is a woodworker is brought to the emergency department 45 minutes after completely severing the thumb of the nondominant left hand just distal to the interphalangeal joint while using a table saw. The amputated digit was wrapped in a moist gauze towel immediately after the injury. The patient smokes one pack of cigarettes daily. Physical examination shows a clean cut through the thumb with minimal tissue loss. Which of the following is the most appropriate management? (A)Great toe transfer (B)Moberg advancement flap (C)Replantation of the thumb (D)Revision amputation (E)Split-thickness skin graft
(C)Replantation of the thumb
An amputated thumb is an indication for replantation in the hands of an experienced microsurgeon with the appropriate team regardless of the level of injury to the thumb. In the scenario described, the thumb is well preserved and the cut is clean with no avulsion injury. Attempts should be made to preserve the length and function of the thumb with replantation.
The importance of the thumb in hand function precludes any further amputation of the thumb. Although the thumb wound would likely close by secondary intention if there is no exposed bone, it is best to preserve as much length as possible, making replantation the operation of choice for the thumb.
A 27-year-old man with a cocaine addiction is brought to the emergency department one hour after sustaining amputation of the thumb of the nondominant left hand at the distal third of the proximal phalanx while using a circular saw. The amputated part was wrapped in a towel and placed on ice. Replantation is performed with an anastomosis of the ulnar digital artery to the radial artery at the anatomic snuffbox with a vein graft. Two weeks after the procedure, there is partial survival of the replanted thumb with exposure of the flexor pollicis longus. Use of which of the following flaps is most appropriate for reconstruction? (A)First dorsal metacarpal artery (B)Moberg (C)Reverse posterior interosseous artery (D)Reverse radial artery (E)Thenar
(A)First dorsal metacarpal artery
A durable, sensate, well-vascularized reconstruction is required. The most appropriate flap for reconstruction of the defect in the scenario described is the first dorsal metacarpal artery. When paired with the first dorsal metacarpal nerve, this flap provides sensate coverage of large defects to the distal volar aspect of the thumb.
The Moberg flap is a sensate advancement flap used to reconstruct volar thumb tip defects of up to 1 cm. This defect is too large. Use of this flap would endanger the blood flow for the replanted thumb, and it would have a high likelihood of partial flap loss.
The reverse radial artery flap is often a fine choice for thumb reconstruction. In the scenario described, however, ligating the radial artery proximal to the harvested flap may compromise the vascular supply to the replanted thumb. The replanted thumb has already displayed signs of potential vascular compromise caused by the loss of the thumb tip after replantation.The thenar flap is a random flap used to cover volar tip defects of the long and ring fingers. The defect in the patient described could not be covered with a thenar flap.
First dorsal metacarpal artery flap
When paired with the first dorsal metacarpal nerve, this flap provides sensate coverage of large defects to the distal volar aspect of the thumb.
Moberg flap
The Moberg flap is a sensate advancement flap used to reconstruct volar thumb tip defects of up to 1 cm.
The reverse posterior interosseous artery flap:
Often used to reconstruct:
The reverse posterior interosseous artery flap is a pedicled fasciocutaneous flap often used to reconstruct the dorsum of the hand or the first web space.
The reverse posterior interosseous artery flap: Sensation
Nonsensate
The reverse radial artery flap and thumb reconstruction
The reverse radial artery flap is often a fine choice for thumb reconstruction. Ligation of the radial artery proximal to the harvested flap may compromise the vascular supply to the replanted thumb and must be considered.
Thenar flap:
Type-
Use-
The thenar flap is a random flap used to cover volar tip defects of the long and ring fingers.
A 45-year-old woman is brought to the emergency department immediately after sustaining a traumatic amputation injury to the thumb of the nondominant left hand. The digit was not recovered. Physical examination shows amputation at the proximal aspect of the proximal phalanx and a volar soft-tissue defect extending to the level of the metacarpophalangeal (MCP) joint. The flexor pollicis longus tendon and digital nerves are lacerated at the MP joint. Which of the following is the most appropriate method of reconstruction?
(A)Completion amputation and index finger pollicization
(B)Transplantation of the contralateral great toe
(C)Transplantation of the ipsilateral great toe
(D)Widening of the first web space with a four-flap Z-plasty followed bycoverage of the thumb with an innervated first dorsal metacarpal artery flap
(E)Widening of the first web space with a four-flap Z-plasty followed by coverage of the thumb with a microneurovascular great toe pulp flap
(C)Transplantation of the ipsilateral great toe
Transplantation of the ipsilateral great toe to the thumb would provide the best function for the patient described. With the degree of shortening that occurs with the level of amputation described, lengthening of the thumb is an important component of reconstruction.
Toe-transplantation for thumb reconstruction: Contralateral versus ipsilateral
Ipsilateral great toe to the thumb
Why go to toe transplantation with amputation at the MCP?
With the degree of shortening that occurs with the level of amputation at the MCP, lengthening of the thumb is an important component of reconstruction.
Timing of toe transplantation after amputation
Toe transplantation can be performed at the time of injury or in a delayed fashion.
For what levels are pollicization of the index finger reserved?
Although pollicization of the index finger can be performed in adults, it is typically reserved for amputation from the level of the carpometacarpal joint to the middle of the metacarpal.
Index pollicization versus toe to thumb transplantation
The functional outcome and aesthetics of index pollicization are inferior to those of great toe transplantation to the residual portion of the thumb.
Options for amputations through the middle to distal aspect of the proximal phalanx
For amputations through the middle to distal aspect of the proximal phalanx, widening of the first web space with Z-plasty and other local flaps or regional flaps, such as reverse radial forearm or posterior interosseous artery flaps, may provide sufficient length and motion for good function.
A healthy 30-year-old woman is brought to the emergency department three hours after sustaining an amputation injury to the thumb and fingers of the dominant right hand when it was caught in an industrial roller. The amputated digits were placed in dry cloth, placed on ice, and transported with the patient. Physical examination shows amputation of the thumb through the interphalangeal and metacarpophalangeal joints. The amputations of the index, long, ring, and small fingers are through the proximal phalanges. Severe crush injuries are also noted in the thumb and index finger. Which of the following is the most appropriate management?
(A)Debridement of the stump and completion amputation of all digits
(B)Part-by-part replantation of the long, ring, and small fingers followed by completion amputation of the thumb and index finger
(C)Part-by-part replantation of the thumb and index finger followed by digit-by-digit replantation of the long, ring, and small fingers
(D)Digit-by-digit replantation of the thumb and index finger followed by part-by-part replantation of the long, ring, and small fingers
(E)Heterotopic replantation of the long finger to the thumb position, ring finger to the long finger position, and small finger to the ring finger position
(E)Heterotopic replantation of the long finger to the thumb position, ring finger to the long finger position, and small finger to the ring finger position
The patient described has a mutilating hand injury with severe, multiple-level, crush amputation to the thumb and index finger rendering them unsuitable for replantation. Heterotopic replantation or transpositional microsurgery is the replantation of a digit in a nonanatomic location when the native digit is unsuitable or unavailable for replantation. There is no definitive rule for heterotopic replantation in cases of mutilating hand injury. The restoration of prehensile function is the primary goal in reconstruction following mutilating hand injuries. The thumb accounts for 40% to 50% of hand function. Other goals include establishment of at least two digits for tripod pinch, functional web spaces, wrist stability, transverse and longitudinal arches of the hand, and aesthetically pleasing appearance. Amputated digits may be replanted at the thumb position to provide restoration of prehensile function. Although establishment of index and middle fingers may be more aesthetically appealing, the use of the long and ring finger and the intervening longer web space will aid in tripod pinch. Priorities in hand reconstruction with heterotopic replantation following mutilating hand injury shouldbe individually tailored to the clinical situation.
Contraindications to replantation of hand and digits include:
- Upper extremity time in the proximal to mid forearm with ischemia time greater than six hours
- Concomitant life-threatening injuries
- Multiple level injury
- Severe crush or avulsion injury
- Extreme contamination
- Systemic illness or surgical history precluding replantation
- Self-mutilation cases and psychotic patients
Heterotopic replantation or transpositional microsurgery in hand surgery
Heterotopic replantation or transpositional microsurgery is the replantation of a digit in a nonanatomic location when the native digit is unsuitable or unavailable for replantation.
Goals in mutilating hand injuries
The restoration of prehensile function is the primary goal in reconstruction following mutilating hand injuries.
Other goals include:
- Establishment of at least two digits for tripod pinch
- Functional web spaces
- Wrist stability
- Transverse and longitudinal arches of the hand
- Aesthetically pleasing appearance.
Prehensile function
Function for seizing/grasping
Multiple digit amputation: Establishing prehensile function / tripod pinch
Amputated digits may be replanted at the thumb position to provide restoration of prehensile function.
Although establishment of index and middle fingers may be more aesthetically appealing, the use of the long and ring finger and the intervening longer web space will aid in tripod pinch.
Two approaches to digit replantation
Digits may be replanted “digit by digit” or “part by part.”
“Digit by digit” replantation / when is it most appropriate?
“Digit by digit” refers to complete replantation of one digit at a time. A “digit-by-digit” repair is suitable in cases where the amputated digits have differing warm ischemia times and the digit in the best condition is replanted first in a salvage effort.
“Part by part” replantation / when is it most appropriate?
“Part by part” refers to grouping the repair of a similar part for all amputated digits. It typically starts with skeletal fixation before soft-tissue repair. The order is typically flexor tendons, extensor tendons, arteries, and veins. A “part-by-part” approach is generally used when the amputated digits all have the same degree of ischemia.
Digit amputations: Considerations in repair of vessels
Arteries are typically repaired first, because venous efflux allows identification of veins for anastomosis. Some authors advocate venous repair first in guillotine amputations to reduce venous stasis and operative time from blood in the operating field.
An otherwise healthy 30-year-old woman comes to the office for consultation regarding severe pain in both thumbs that has been worsening during the past three years. Physical examination shows severe transverse curvature of the nails of both thumbs starting from the proximal nail bed and increasing distally. The patient has no history of serious infection. Which of the following is the most appropriate management?
(A)Coverage with cross-finger flap from the dorsum of the index finger
(B)Digital and wrist sympathectomy
(C)Elevation of the nail plate and dermal grafting under the matrix
(D)Removal of the nail plate and ablation of the matrix
(E)Serial compression splinting
(C)Elevation of the nail plate and dermal grafting under the matrix
Pincer-nail syndrome
Pincer-nail syndrome has been described as constriction in the distal portion of the shape of the nails such that there is an excessive transverse curvature of the nail plate that increases from the proximal to distal, resulting in constant severe pain.
Etiologies of pincer-nail syndrome
The etiology of the deformity has since been attributed to many factors including psoriasis, ill-fitting shoes, developmental anomalies, β-blocking agents such as practolol, allergic reaction, underlying epidermoid cyst, subungual exostosis, and osteoarthritis.
Correction of pincer-nail syndrome
Several authors have used dermal and collagen matrix grafts for correction. This surgery corrects the deformity by grafting soft-tissue collagen under the nail matrix, reelevating the edges.
A 24-year-old man has defects over the dorsal aspect of the proximal phalanges of the index and long fingers after sustaining a grinder injury. The extensor tendon of the index finger is denuded of peritenon over a 1-cm-diameter area extending from the metacarpophalangeal joint to the proximal interphalangeal joint. A skin graft is planned to reconstruct the defect over the long finger. Which of the following flaps is most appropriate to reconstruct the defect over the index finger? (A)Adipofascial turndown (B)Cross-finger (C)Dorsal thumb metacarpal transposition (D)Reverse posterior interosseous artery (E)Reverse radial forearm
(A)Adipofascial turndown
Small, dorsal defects of the fingers can be reconstructed via a number of local flaps; as in many other parts of the body, adipofascial turnover flaps have been developed for the upper extremity, hand, and fingers.
For coverage of dorsal digital defects, adipofascial turnover flaps are designed with the base of the flap proximal to the defect. The flap itself is designed to be 2 to 4 mm wider than the skin defect with a base-to-length ratio of 1:1.5 to 1:3. A longitudinal incision over the center of the flap allows dissection of the flap from the overlying skin. The adipofascial flap is then elevated from proximal to distal from the underlying paratenon. Elevation stops approximately 0.5 to 1 cm proximal to the defect to create the base of the flap; the flap is then turned over into the digital defect and covered with a split-thickness skin graft.
Given the damage to the adjacent long finger, a cross-finger flap would not be possible. A transposition flap from the dorsal thumb may suffice for first web resurfacing but will not adequately reach the dorsal index finger.
Both the posterior interosseous artery and radial-artery–based flapsare capable of resurfacing sizable defects on the hand and fingers; however, the added morbidity of harvesting these flaps does not warrant their use when a more suitable local flap is available.
Advantages of adipofascial turndown flaps (fingers)
Advantages of these flaps include:
- Almost limitless donor sites
- Single stage reconstruction
- Minimal donor site morbidity
Adipofascial turnover flaps for dorsal digital defects: Procedure
For coverage of dorsal digital defects, adipofascial turnover flaps are designed with the base of the flap proximal to the defect. The flap itself is designed to be 2 to 4 mm wider than the skin defect with a base-to-length ratio of 1:1.5 to 1:3. A longitudinal incision over the center of the flap allows dissection of the flap from the overlying skin. The adipofascial flap is then elevated from proximal to distal from the underlying paratenon. Elevation stops approximately 0.5 to 1 cm proximal to the defect to create the base of the flap; the flap is then turned over into the digital defect and covered with a split-thickness skin graft.
A 57-year-old man is referred to the office by his primary care physician for management of contracture of the little finger (Dupuytren) that has been present for more than five years. Flexion of the digit has been increasing during the past year. Surgical management is planned via a transverse palmar approach with longitudinal incisions based over the contracted cord and later converted to the necessary V-Y advancement Z-plasties. Which of the following is the most likely long-term outcome in this patient? (A)Anesthesia of the digit (B)Carpal tunnel syndrome (C)Complex regional pain syndrome type I (D)Cord recurrence (E)Vascular insufficiency
(D)Cord recurrence
Complications of Dupuytren disease have been reported to be 17% overall. Nerve injuries can be a devastating complication after surgery for Dupuytren disease.
Overal % of complications of Dupuytren disease
Complications of Dupuytren disease have been reported to be 17% overall.
Why are the digital nerves more prone to injury in Dupuytren disease?
The digital nerves are displaced medially by the spiral cord, making them more prone to injury.
Nerve resection in Dupuytren disease occurs in ___% of patients
Fortunately, nerve transection is relatively rare, reported in only 1.5% of patients with Dupuytren disease.
Complex regional pain syndrome is also known as
Reflex sympathetic dystrophy
Complex regional pain syndrome occurs in ___% of patients after Dupuytren disease
Complex regional pain syndrome (reflex sympathetic dystrophy) may occur after Dupuytren disease, but this is an uncommon complication (approximately 4% to 8%).
Recurrence after Dupuytren: ___%
Recurrence after Dupuytren is significant; a recent study placed recurrence at 18% to 24%.
A 23-year-old man comes to the emergency department immediately after he sustained an injury to the tip and nail bed of the index finger of the right hand. Physical examination shows avulsion of the nail bed and nail plate. Ninety percent of the sterile matrix is missing and cannot be located on the underside of the nail plate. Which of the following is the most appropriate intervention for repair of the missing nail bed?
(A)Application of regenerative dermal matrix (Alloderm)
(B)Grafting of the sterile matrix from the great toe
(C)Grafting of the sterile matrix from the injured nail bed
(D)Healing by secondary intention
(E)Skin grafting from the hypothenar area
(B)Grafting of the sterile matrix from the great toe
If the area of loss of sterile matrix is significant, grafting with sterile matrix provides the best outcome. More than half of the sterile matrix is missing from the injured nail bed of the patient described, which is not enough to provide for coverage of the defect. Therefore, use of sterile matrix from the great toe as the donor site is the most appropriate intervention in the scenario described.
Regenerative dermal matrix is not sterile matrix and application of it would not reconstruct either the germinal or sterile matrix.
Allowing the nail bed injury of the patient described to heal by secondary intention would result in nail nonadherence and risk bony infection.
The sterile matrix should not be reconstructed with a standard skin graft because this would also result in nail nonadherence and risk frequent infection.
A 55-year-old man with well-controlled type 1 diabetes mellitus and a history of kidney transplantation comes to the clinic becausehe has had increasing pain, swelling, and redness of the right index finger over the past four days. Five days ago, he sustained an injury to the finger when a thorn became lodged under the skin while he was gardening. Medical records show that hemoglobinA1c was 12% three weeks ago. Temperature is 37.9EC (100.2EF). On laboratory studies, white blood cell count is 16,000/mm3 and serum glucose level is 495 mg/dL. Examination of the right hand shows severe flexor tenosynovitis of the index finger. Which of the following factors in this patient increases his risk of amputation of the digit?
(A) Hemoglobin A1c greater than 10%
(B) History of kidney transplantation
(C) Insulin dependence
(D) Serum glucose level greater than 450 mg/dL
(E)White blood cell count greater than 14,000/mm3
(B) History of kidney transplantation
History of renal failure or kidney transplantation is associated with the highest risk of amputation in diabetic patients with hand infections.
Amputation rates in this population range from 75% to 100%. Multiple studies have shown that diabetes mellitus negatively impacts the prognosis of hand infections. Hand infections in patients with diabetes take longer to resolve and are more likely to require multiple debridements than infections in patients without diabetes. In addition, initiation of treatment is more likely to be delayed in patients with diabetes.
Insulin dependence, history of poorly controlled diabetes (as indicated byelevated hemoglobin A1c), white blood cell count greater than 14,000/mm3, and serum glucose level greater than 450 mg/dL have not been shown to significantly increase the risk of amputation in diabetic patients with hand infections.
History of __________ is associated with the highest risk of amputation in diabetic patients with hand infections
History of renal failure or kidney transplantation is associated with the highest risk of amputation in diabetic patients with hand infections.
History of renal failure or kidney transplantation AND diabetes is associated with the ___% risk of amputation in patients with hand infections.
Amputation rates in this population range from 75% to 100%.
A 48-year-old woman is referred to the office by her primary care physician for evaluation of a painless ulcer on the tip of the index finger of the right hand that has been present for the past three months. Medical history includes scleroderma with thin, tight, fibrotic skin on the face and perioral region. On physical examination, dry eschar and visible bone are noted at the tip of the index finger. The skin of the other digits is thin and shiny. No flexion contractures of the interphalangeal joints are noted. Radiographs of the index finger show mild resorption of the tuft. Which of the following is the most appropriate management at this time?
(A)Amputation of the distal phalanx and direct closure of the stump at the level of thedistal interphalangeal joint
(B)Conservative debridement of the soft tissue of the tip of the finger and resection of exposed bone
(C)Ray amputation of the digit and primary closure
(D)Resection of the distal phalanx to the level of the distal interphalangeal joint and soft-tissue healing by secondary intention
(E)Urgent digital sympathectomy and debridement of eschar
(B)Conservative debridement of the soft tissue of the tip of the finger and resection of exposed bone
Scleroderma is an autoimmune disease that includes a disorder of the connective tissue and small blood vessels.
Tip ulcerations are common because of the poor circulation associated with scleroderma. Many of these ulcerations will successfully heal over time without surgery. An initial conservative approach should therefore be taken. This approach includes conservative debridement, topical antibiotics (eg, silver sulfadiazine), and limited resection of exposed bone. If active infection is present, antibiotics should be administered.
Ulceration of the fingertips in CREST syndrome occurs secondary to:
Poor circulation
Skin breakdown in CREST syndrome over the PIP and MPJ’s occurs due to:
Bony joint deformities and poor circulation
Natural course of tip ulcerations in scleroderma
Many of these ulcerations will successfully heal over time without surgery.
Initial management of tip ulcerations in scleroderma
An initial conservative approach should be taken: This approach includes conservative debridement, topical antibiotics (eg, silver sulfadiazine), and limited resection of exposed bone. If active infection is present, antibiotics should be administered.
Tip ulcerations in scleroderma: If these fail to respond to conservative treatment-
If ulceration and pain fail to respond to conservative treatment, more aggressive intervention is required, including amputation and possible digital sympathectomy. Unfortunately, many patients who undergo digital sympathectomy continue to have pain and suffer recurrent ulceration.
A 72-year-old man is referred to the hand clinic because he has had paronychia of the left thumb for the past three months. Treatment by the patient’s primary care physician, including warm soaks and antifungal therapy, resulted in no change in his condition. Physical examination of the finger shows a 0.3 x 0.6-cm erythematous lesion extending from the lunula to the eponychial fold and involving the nail bed. No palpable lymph nodes are noted. Radiography shows no bony involvement. Biopsy of the lesion shows moderately differentiated squamous cell carcinoma. Which of the following is the most appropriate management?
(A)Amputation of the entire distal phalanx
(B)Complete ablation of the nail matrix
(C)Excision of the lesion with 2-mm margins
(D)Excision of the lesion with 15-mm margins
(E)Ray amputation
(A)Amputation of the entire distal phalanx
The condition of the patient described requires amputation of the entire distal phalanx.
Chronic paronychia is usually caused by a candidal infection. Failure of medical treatment with antifungals requires:
- Culture
- Radiographic evaluation to exclude bony involvement
- Biopsy to exclude malignancy, particularly squamous cell carcinoma.
Squamous cell carcinoma is the most common primary malignancy of the hand. Lesions not involving the nail bed require excision with 1-cm margins. Tumors involving the nail bed or bone necessitate amputation of the entire distal phalanx. Ray amputation of the thumbresults in excessive functional loss of the extremity and does not improve long-term survival.
Chronic paronychia is usually caused by:
Chronic paronychia is usually caused by a candidal infection.
Chronic paronychia: Failure of medical treatment
Chronic paronychia is usually caused by a candidal infection. Failure of medical treatment with antifungals requires:
- Culture
- Radiographic evaluation to exclude bony involvement
- Biopsy to exclude malignancy, particularly squamous cell carcinoma.
Most common primary malignancy of the hand:
Squamous cell carcinoma is the most common primary malignancy of the hand.
Margins for squamous cell carcinoma of the hand
Lesions not involving the nail bed require excision with 1-cm margins. Tumors involving the nail bed or bone necessitate amputation of the entire distal phalanx.
A 30-year-old man comes to the emergency department 30 minutes after he sustained traumatic avulsion amputation of the thumb at the level of the interphalangeal joint. The amputated digit was wrapped in a wet towel immediately after the injury and has been kept on ice since that time. Physical examination shows complete avulsions of the extensor pollicis longus and flexor pollicis longus tendons from their muscle bellies. Which of the following is the most appropriate management of this patient’s injury?
(A)Replantation and tendon repair
(B)Replantation of the amputated digit and immediate fusion of the interphalangeal joint
(C)Revision amputation and delayed pollicization
(D)Revision amputation and subsequent transfer of the great toe
(E)Revision amputation, immediate shortening of the bone, and closure of the skin
(B)Replantation of the amputated digit and immediate fusion of the interphalangeal joint
Because the extensor pollicis longus (EPL) and flexor pollicis longus (FPL) tendons are avulsed, repair or reconstruction of their function is difficult. When these tendons are reinserted, there is a risk of infection. The main contribution of the thumb to overall hand function is through its length and ability to oppose the fingers to grab and hold objects. The critical length of the thumb is the level of the interphalangeal (IP) joint. It is optimal to preserve the length of the thumb to at least the IP level. Thumb length is more important than motion.
Thumb function is not significantly altered with fusion of the IP joint. Furthermore, fusion of the IP joint can allow for less tension across the microneurovascular repairs. This has been shown to improve survival rates for thumb replantations as well as produce reliable recovery of two-point discrimination through nerve repairs that are not under tension.
If the IP joint of the thumb is fused, there is no need to repair the FPL tendon.
What is the main contribution of the thumb to hand function?
The main contribution of the thumb to overall hand function is through its length and ability to oppose the fingers to grab and hold objects.
What is the critical important length of the thumb?
The critical length of the thumb is the level of the interphalangeal (IP) joint. It is optimal to preserve the length of the thumb to at least the IP level.
Thumb function: Length versus motion
Thumb length is more important than motion.
Fusion of the IPJ and thumb function
Thumb function is not significantly altered with fusion of the IP joint.
Fusion of the thumb IP joint and thumb replantatino
Furthermore, fusion of the IP joint can allow for less tension across the microneurovascular repairs. This has been shown to improve survival rates for thumb replantations as well as produce reliable recovery of two-point discrimination through nerve repairs that are not under tension. Furthermore, shortening of the thumb allows for avoidance of the potential need for grafts to repair the artery or nerves.
Thumb amputation: Avulsion of the EPL and FPL tendons
Because the extensor pollicis longus (EPL) and flexor pollicis longus (FPL) tendons are avulsed, repair or reconstruction of their function is difficult. When these tendons are reinserted, there is a risk of infection.
A 44-year-old man comes to the emergency department immediately after he sustained an injury to the tip of the left thumb while working with a table saw. Physical examination shows a 1.5 × 1.5-cm wound involving the volar tip of the thumb with bone visible within the base of the wound. Which of the following is the most appropriate management? (A)Cross-finger flap (B)Island Moberg flap (C)Secondary healing (D)Skin grafting (E)Thenar flap
(B)Island Moberg flap
The Moberg flap is the most effective intervention for thumb tip defects of 1.5 cm or smaller. Some of the tactics that have been described to facilitate distal advancement of the flap include flexion of the thumb interphalangeal crease, extension of the lateral incisions proximal to the metaphalangeal crease, and islandization of the flap by releasing the skin at the base of the flap and skin grafting the donor wound.
The cross-finger flap can be used for the thumb but is best suited for fingers of younger patients because of the risk of flexion contractures when used in older patients. Secondary healing is inappropriate in the case described because of the large size of the wound. Skin grafting is not appropriate for the patient described because bone is exposed. The thenar flap is harvested from the thumb and, therefore, is not used to reconstruct the thumb.
What is the most effective intervention for thumb tip defects of 1.5 cm or smaller?
The Moberg flap is the most effective intervention for thumb tip defects of 1.5 cm or smaller.
Tactics to facilitate distal advancement of a Moberg flap to the thumb tip
Some of the tactics that have been described to facilitate distal advancement of the flap include flexion of the thumb interphalangeal crease, extension of the lateral incisions proximal to the metaphalangeal crease, and islandization of the flap by releasing the skin at the base of the flap and skin grafting the donor wound.
What patient population is best suited for the cross-finger flap for the thumb?
The cross-finger flap can be used for the thumb but is best suited for fingers of younger patients because of the risk of flexion contractures when used in older patients.
A 65-year-old man who plays golf three times weekly has severe Dupuytren contracture of the small finger of the dominant right hand. The dense cord extends along the ulnar aspect of the hand and digit. The contracture of the metacarpophalangeal joint is 60 degrees, and the contracture of the proximal interphalangeal joint is 95 degrees. Which of the following is the most likely origin of the ulnar cord? (A)Abductor digiti minimi (B)Abductor pollicis brevis (C)Antebrachial fascia (D)Cleland ligament (E)Volar carpal ligament
(A)Abductor digiti minimi
In the small finger, the ulnar cord typically originates from the musculotendinous junction of the abductor digiti minimi. From this location, the pretendinous band, spiral band, lateral digital sheath, and Grayson ligament can become involved, which can result in significant contractures at the metacarpophalangeal and proximal interphalangeal joints.
The other structures listed are not typically involved in Dupuytren contracture. The abductor pollicis brevis is the most radial thenar muscle and does not affect the ulnar cord. The antebrachial fascia is the superficial forearm fascia and is not relatedto Dupuytren contracture. The contractile cords involve Grayson ligaments and not Cleland ligaments. The Cleland ligament is dorsal to the neurovascular bundle. The volar carpal ligament covers the Guyon canal.
In the small finger, the ulnar cord typically originates from:
In the small finger, the ulnar cord typically originates from the musculotendinous junction of the abductor digiti minimi.
