Chief Complaint
Traumatic amputation of the middle and ring finger of the R hand
Family History
(-) Hypertension (-) Diabetes Mellitus (-) Bronchial Asthma (-) Thyroid Disease
Review of Systems
General:
(-) fever, weakness
HEENT:
(-) blurring of vision, hearing loss, sore throat, frequent cough and colds
Respiratory:
(-) difficulty of breathing
Cardiovascular
(-) chest pain, easy fatigability
Review of Systems
Gastrointestinal:
(-) nausea, vomiting, changes in bowel habits
Urinary:
(-) dysuria, hematuria
Endocrine:
(-) temperature intolerance
Hematopoietic:
(-) easy bruisability, poor wound healing
Nervous/Psychiatric:
(-) headache, loss of consciousness, slurring of speech
Physical Examination
General Survey:
Conscious, coherent, not in distress, ambulatory
Vital Signs:
BP: 120/70 HR: 64 RR: 18 T: 37.3C Wt: 62.7 kg Ht: 170cm
HEENT:
Anicteric Sclerae, Pink palpebral conjunctiva, No nasoaural discharge
Physical Examination
Neck:
Supple, no cervical lymphadenopathies
Breast:
Symmetrical, normal contour, no discoloration, no palpable masses, no nipple discharge
Respiratory:
Symmetric chest expansion, no retractions, clear breath sounds
Cardiovascular:
Adynamic precordium, normal rate and regular rhythm, no murmurs
Physical Examination
Neurologic:
Conscious, coherent, oriented to person, place, and time, no gross motor and sensory deficits
FINGERTIP AMPUTATION
Objectives
1. Discuss the anatomy of the fingertip
Background
One of the most common injuries of the hand Common types of injuries:
Blunt or crush injuries to the fingernail Nail root avulsions Fracture of terminal phalanx Sharp or shearing injuries Burns and frostbite
Epidemiology
~ 10% of all accidents encountered in the ED involved the hand 15-24% of fingertip injuries involve damage to the nail bed
Fingertip Anatomy
Distal phalanx Extensor Tendon Flexor Tendon Pulp Nail
Eponychium Paronychium Hyponychium Lunula Nail matrix Nail fold
Fingertip Anatomy
Digital artery Digital nerve
Workup
Radiographs
Management
Goals:
Provide a sensate, durable tip with adequate bony support for the nail
Treatment of choice depends on the geometry of the defect and whether or not bone is exposed
Management
Allens Classification Type 1: pulp only Type 2: pulp + nail bed Type 3: distal phalangeal fracture with associated pulp and nail loss Type 4: lunula, distal phalanx, pulp, nail loss
Treatment Options
Secondary intention healing Skin grafting Flaps Terminalization or revision amputation Distal replantation
Complications
Beaking of the nail Loss of pulp contour Hypo- or hyperaesthesia
Treatment Options
Flaps
Depends on the size and site of the defect Experience of the surgeon Patients choice Examples:
VY advancement Cross Finger Foucher
Treatment Options
VY Advancement Flap Indication:
Angle of fingertip amputation is either oblique with more tissue loss dorsally or transverse.
Can be performed only if significant palmar tissue is available for dorsal advancement
Thumb fingertip amputation Less than 1.5 cm of advancement is required for coverage
Treatment Options
Reamputation
With exposed bone In adults with injuries that have <5 mm of sterile nail matrix present Relatively indicated in patients with significant systemic conditions, for whom regional flaps are contraindicated and the other techniques like skin graft or open technique are not possible
Complications
Wound hematoma, infection, necrosis Open Healing: Insensitivity at finger tips Skin Graft: Induration or fissuring of the graft, insensitivity Reamputation: