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Identifying Data

SC 31 yo/M Single Filipino Seafarer

Chief Complaint
Traumatic amputation of the middle and ring finger of the R hand

History of Present Illness


2 weeks PTA
R hand w/ gloves accidentally got caught in an aircon accomodation fan Amputation of the tip of the middle and ring finger First aid given Applied Quik clot Given amoxicillin

History of Present Illness


8 days PTA
Sought consult in Africa Advised debridement and skin grafting Opted to have the procedure in the Philippines

Past Medical History


(-) Hypertension (-) Diabetes Mellitus (-) Bronchial Asthma (-) Thyroid Disease (-) Previous Surgeries (-) Allergies to Food and Drugs

Family History
(-) Hypertension (-) Diabetes Mellitus (-) Bronchial Asthma (-) Thyroid Disease

Personal and Social History


Right-handed Works with machineries in a ship Non-smoker Non-alcoholic beverage drinker Exercises regularly

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

Skin, Nails, Hair:


No jaundice, flushing, and cyanosis Hair black, in normal distribution, with no signs of alopecia

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

Treatment Option: Secondary Intention Healing


Indications
< 1cm2 of the tip or pulp bone not exposed Injury is in a child

Treatment Option: Skin Graft


Skin Grafting
Larger injuries No exposed bone Preferred donor site: full-thickness graft from hypothenar area
Durability Cosmesis Convenience

Treatment Option: Skin Graft


Other sites:
Medial aspect of the arm distal to axilla Volar side of the forearm and wrist Amputated part of the fingertip, if it is available

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

Treatment Option: Flaps


Volar Flap Enhancement

Thumb fingertip amputation Less than 1.5 cm of advancement is required for coverage

Treatment Option: Flaps


Cross-finger Flap When local flaps are not possible Maintaining the remaining length is essential In multiple digit injury Avoided in patients >50 years and in hands with arthritis or a tendency toward finger stiffness

Treatment Option: Flaps


Thenar Flap
For fingertip amputation with exposed bone

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:

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