Introduction Injury to the finger with variable involvement of soft tissue, bone, and tendon Goals of treatment sensate tip durable tip bone support for nail growth Prognosis improper treatment may result in stiffness and long-term functional loss Anatomy Fingertip anatomy eponychium soft tissue on the dorsal surface just proximal to the nail paronychium lateral nail folds hyponychium plug of keratinous material situated beneath the distal edge of the nail where the nail bed meets the skin lunula white portion of the proximal nail demarcates the sterile from germinal matrix beneath nail bed sterile matrix where the nail adheres to the nail bed germinal matrix proximal to the sterile matrix responsible for 90% of nail growth Presentation History mechanism avulsion laceration crush Physical exam inspection often, characteristics of laceration will guide management presence or absence of exposed bone range of motion flexor and extensor tendon involvement Imaging Radiographs required imaging AP/lateral radiographs to assess for bony involvement Treatment Nonoperative healing by secondary intention indications adults and children with no bone or tendon exposed with < 2cm of skin loss children with exposed bone Operative primary closure (revision amputation) indications finger amputation with exposed bone and the ability to rongeur bone proximally without compromising bony support to nail bed full thickness skin grafting from hypothenar region indications fingertip amputation with no exposed bone and > 2cm of tissue loss flap reconstruction indications exposed bone or tendon where rongeuring bone proximally is not an option Surgical Techniques Secondary intention technique initial treatment with irrigation and soft dressing after 7-10 days, soaks in water-peroxide solution daily followed by application of soft dressing and fingertip protector complete healing takes 3-5 weeks Full thickness skin grafting from hypothenar region technique split thickness grafts not used because they are contractile tender less durable donor site is closed primarily graft is sutured over defect cotton ball secured over graft helps maintain coaptation with underlying tissue post-operative care cotton ball removed after 7 days range of motion encouraged after 7 days Primary closure with removal of exposed bone (revision amputation) technique must ablate remaining nail matrix prevents formation of irritating nail remnants if flexor or extensor tendon insertions cannot be preserve, disarticulate DIP joint transect digital nerves and remaining tendons as proximal as possible palmar skin is brought over bone and sutured to dorsal skin Flap reconstruction (see below) Flap Techniques By Region Flap treatment options determined by location of lesion 1. Finger Tip Straight or Dorsal Oblique laceration • V-Y Advancement flap • Digital island artery Volar Oblique laceration • Cross finger flap (if > 30 yrs) • Thenar flap (if< 30 yrs) • Digital island artery reverse cross finger (for nail bed sterile matrix and eponychial fold losses) 2. Volar Proximal Finger • Cross finger (if > 30 yrs) • Axial flag flap from long finger 3. Dorsal Proximal Finger & MCP • Reverse cross finger • Axial flag flap from long finger 4. Volar Thumb • Moberg Advancement Volar Flap (if < 2 cm) • FDMA (if > 2 cm) • Neurovascular Island Flap (up to 4 cm) 5. Dorsal Thumb • First Dorsal Metacarpal Artery (FDMA) flap 6. First Web Space • Z-plasty with 60 degree flaps • Posterior interosseous fasciocutaneous flap (if > 75%) 7. Dorsal Hand • Groin Flap Flap Reconstruction Techniques V-Y advancement flap indications straight or dorsal oblique finger tip lacerations Digital island artery indications straight or dorsal oblique finger tip lacerations volar oblique finger tip lacerations advantages best axial pattern flap Cross finger flap indications volar oblique finger tip lacerations in patients > 30 years advantages leads to less stiffness Reverse cross finger flap indications dorsal finger & MCP lacerations Thenar flap indications volar oblique finger tip lacerations to index or middle finger in patients < 30 years advantages improved cosmesis Axial flag flap from long finger indications volar proximal finger dorsal proximal finger & MCP lacerations Moberg advancement volar flap indications volar thumb if < 2 cm Neurovascular island flap indications volar thumb up to 4 cm First dorsal metacarpal artery flap indications dorsal thumb lacerations volar thumb lacerations if > 2 cm technique based on 1st dorsal metacarpal artery Z-plasty with 60 degrees flaps indications first web space lacerations technique can lead up to 75% increase in length Posterior interosseous fasciocutaneous flap indications first web space lacerations Groin flap indications lesions to dorsal hand Complications Flap failure cause inadequate arterial flow vasospasm often leads to thombosis at anastamosis inadequate venous outflow Hook nail deformity cause tight tip closure insufficient bony support treatment variety of reconstructive procedures have been described