Management of Fingertip Injuries - jkscience.org Article- 17(3) issue.pdf · fingertip injuries in 60 children by Das SK, et al (10), trapdoor injury was the major cause accounting

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ORIGINALARTICLE

From the Department of G. Surgery, Govt. Medical College, Jammu J&K IndiaCorrespondence to : Dr. Ratnakar Sharma, Assistant Professor, Department of G. Surgery, Govt. Medical College, Jammu J&K India

Management of Fingertip InjuriesRatnakar Sharma, Akashdeep Singh, Ravinder Singh

Fingertip injuries represent the most common type ofinjuries seen in the upper extremity. The fingertip hasbeen defined by Jacques Michon (1) as part of the fingerdistal to the insertion of extensor and flexor tendons.Thesurgeon should have a flexible approach to fingertipinjuries. In choosing a method of reconstruction, one mustconsider the factors such as number of digits injured,location of the wound, primary function of the digit,occupation, sex, age, time factor, facilities available andabove all socio-economic factors.

Russel RC (2) classified fingertip injuries dependingon the level and angle as follows :

Type A: Volar skin and pulp loss without exposed bonecan be skin-grafted or left alone would heal by secondaryintention.

Type B: Large volar skin and pulp loss with exposeddistal phalanx.

Type C: Guillotine fingertip amputations.Type D: Dorsally directed fingertip amputation with

little remaining nail bed.The reconstructive modality in finger tip injury is largely

determined by the type of injury sustained as per theclassification of Russel.Materials and Methods

A retrospective study was conducted on 50 patientshaving sustained fingertip injuries over a period of 3 years.The demographic data including age, sex, occupation,cause of injury, hand and the digit sustaining injury, thetype of defect and the reconstructive modality were

recorded and analysed. All the patients had undergoneroutine investigations as well as screening for HIV andViral Hepatitis. All the patients were given antibioticcoverage against Gram +ve,Gram -ve and anaerobes aswell as anti tetanus prophylaxis.Results

A total of 50 patients having sustained fingertip injurieswere treated over a period of 3 years. Majority of thepatients were in age group of 31- 40 years (20 patients).The youngest patient in the series was 2 years old male

Introduction

AbstractFingertip injuries are one of the most common injuries sustained by human beings owing to various reasonsas domestic, occupational, road traffic accidents or due to violence. The injury to the fingertip needsproper assessment and reconstruction so as to provide the proper tissue replacement.we describe ourexperience of 50 patients of fingertip injuries requiring reconstruction using one or other modality over aperiod of three years presenting to our hospital.

Key WordsFingertip Injuries, Presentation, Modes of Reconstruction

Fig.1 Composite Grafting of Index Finger Tip

Fig2. Volar V Y flap for Right Middle Fingertip Defect

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Fig. 3 Cross Finger Flap for Right Middle Finger defect

Fig.3 First Dorsal Metacarpal Artery Flap for Coverage of Thumb Tip Defect

Age Group No. of Patients Percentage

< 10 Years 5 10.0 %11-20 Years 4 8 %21-30 Years 16 32 %31-40 Years 20 40 %41-50 Years 2 4 %51-58 Years 3 6 %

Total 50 100.0 %

Table 1. Age Distribution of Cases

Sex No. of Patients Percentage

Male 38 76% Female 12 24 % Total 50 100 %

Table 2. Sex Distribution of Cases

Occupation No. of Patients Percentage

Labourer / Factory Worker 30 60%House Wives 12 24%School Going 5 10.0 %Kids At Home 3 6 %Total 50 100.0 %

Table 3. Occupation Wise Distribution

Cause of Injury No. of Patients Percentage

Trap Door Injury 3 6%Fall Of Heavy Objects 28 56 %Knife / Sharp Objects 9 18 %Road Traffic Injury 6 12 %Others 4 8 %Total 50 100.0 %

Table 4. Cause of Injury

Hand Injured No. of Patients Percentage

Dominant 42 84 % Non-Dominant 8 16 % Total 50 100.0 %

Table 5. Dominance of Hand

Fingers Injured No. of Patients Percentage

One Finger 41 82% Two Fingers 7 14 % More Than Two 2 4 % Total 50 100.0%

Table 6. Number of Finger Injury

Type of Finger Injured Number Percentage

Index Finger 27 45% Middle Finger 18 30% Ring Finger 9 15% Little Finger 2 3.4% Thumb 4 6.6% Total 60 100.0 %

Table 7. Type of Finger Injury

child whereas the oldest patient was 56 years old female.Majority of the patients were male (38 patients).Labourers or the factory workers were the most commonto have sustained such injuries(30 patients).

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Type of Injury No. of Fingers Percentage

Type A 9 15 %Type B 30 50%Type C 12 20%Type D 9 15%Total 60 100 %

Table 8. Type of Injury

Fall of heavy objects was the commonest cause ofinjury( 28 patients). Trap door injury was the commonestmode of injury among children. Dominant hand sustainedtrauma in 42 patients. Single digit was injured in 41patients whereas 7 patients sustained injury to 2 fingersand 2 patients sustained injuries to more than 2 fingers.In total 60 digits sustained injury in 50 patients. Indexfinger was the commonest to suffer (27patients). TypeB injury accounted for maximum number of cases ( 30patients). Skin grafting of defect was done in 8 patientswhereas composite graft from amputated part was usedto resurface the defect in 4 patients. Local flaps wereutilized as reconstructive modalities in 22 patients ( volarv-y flap(12), kutler flap(6), moberg flap(4) ). Regionalflaps were employed in 26 patients ( cross finger flap(14) , thenar flap(4), first dorsal metacarpal artery flap(4),de epithelized cross finger flap(4) ). No patient had anymajor complication out of surgical procedure. Partial graftloss was seen in four patients. Joint stiffness arising outof regional flaps was seen in 4 patients which wasimproved with physiotherapy. Partial flap necrosis wasencountered in 1 patient having undergone first dorsalmetacarpal artery flap for thumb defect. Debridementand dressings were all needed to salvage the flap.Discussion

Finger tips are one of the most important end organsof human beings required for proprioception and itsprehensile function. Houston JT (3) stressed uponconserving the lenth of the digits. In our study 50 patientshaving sustained fingertip injuries to 60 digits wereevaluated and treated by suitable reconstructive modalities.

Maximum number of patients were in age group of 31to 40 years (20 patients). The youngest patient was 2year old child while the oldest was 56 years old . Lee LP,et al (4) found the incidence of fingertip injuries to behighest in the age range between 31 to 50 years.

In another series of 130 patients by Fattah JH , et al(5), the majority of patients were in age group of 21 to 40years. Males outnumbered females in our study andcomprised 76% of cases( 38 patients). Saaiq M (6), inhis study on 138 patients of fingertip injuries found theincidence to be higher in males accounting for 84.78 %of cases. Saraf S, et al (7), in their study on 150 patientsof fingertip injuries found the incidence to be higher inmales as compared to that in the females (90:60). In ourstudy, incidence of fingertip injuries was highest amonglabourers or factory workers accounting for 60% ofpatients (30 patients). Bernard SL, et al (8), in their studyon fingertip injuries observed that such injuries are morecommonly seen in children and in men who work withmoving machinery. Trybus M, et al (9), in their studyobserved that fingertip injuries were more due tohousehold trauma (45.3 %) as compared to injuriessustained at work (19.7 %). Fall of heavy objects wasthe commonest mode of trauma in our study groupaccounting for 56 % of cases. Saaiq M (6) observed thatthe crush injury due to machine accounted for 38.40 %of fingertip injuries whereas 15.94 % of their patientssustained fingertip injury arising out of road trafficaccidents. In our study, all the kid at home (n=3) sustainedfingertip injury due to trapdoor (100 %). In a study offingertip injuries in 60 children by Das SK, et al (10),trapdoor injury was the major cause accounting for 32cases (53.33 %).The dominant hand suffered trauma inmajority of cases (84 %). Saaiq M (6), in his study on138 patients of finger injuries found the incidence to behigher in right hand which was the dominant hand in 136

Mode of Treatment Number

Split skin graft of defects 8

Composite graft from amputed part 4Local flaps (22)Volar V-Y flap 12Kutler flap 6Moberg flap 4

Regional flaps (26)Cross-Finger flap 14Thenar flap 4First dorsal metacarpal artery flap 4De epithelized cross finger flap 4

Total 60

Table 9. Modalities of Treatment

Type of complications Number of cases

Partial graft loss 4Joint stiffness (Cross finger flap - 1 case) (Thenar flap -2 cases ) (Moberg flap - 1 case ) 4Partial flap necrosis (First dorsal metacarpal artery flap) 1

Table 10. Showing Complications

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References

cases (98.55 %). In our study, index finger was the mostaffected digit (45%) followed by the middle finger (30%).Lee LP, et al (4), in their study of 125 patients withfingertip injuries found the involvement of the index fingerto be most common (41.6%) followed by middle finger(37.6%). In our study, type B injury was found to be thecommonest and was seen in 30 cases (50%cases), theinjuries being classified depending upon level and angle.Lemmom JA, et al (11), in their study on soft tissue injuriesof fingertip classified the injuries as per the level and theangle of injury. In our study, skin grafting of the defectswas done in 8 patients. Composite graft from amputedpart was used to resurface the defect in 4 patients. EberlinKR, et al (12) published the role of composite graftingfor pediatric fingertip injuries with good outcome. 12patients in our study group underwent Volar V-Y flap forfingertip reconstruction. Atasoy E , et al (13) publishedthe results of 61 patients who underwent Volar V-Y flap.Kutler flap was employed for restoration of fingertip in6 cases. Freiberg, et al (14) ) had twenty-two of theirthirty patients with Kutler flaps as treatment option forfingertip injury. Four cases of oblique volar pulp loss ofthumb were treated with Moberg flap( volar thumbadvancement flap).Stiffness of interphalangeal joint wasnoted in one case even after two months ofphysiotherapy. However, the mild flexion contracture didnot come in the way of daily activities of the patient.Fassler (15) described the utility of Mobergadvancement flap in their cases of soft tissue defects ofthumb tip requiring mobilization of tissue greater than 2cm in length.

In this study, 14 patients were offered cross fingerflap coverage for fingertip injury.Edgerton , et al (16), intheir review of 546 cross finger flaps noted a survivalrate of 98.7%. Lee WP , et al (17) stressed the utility ofcross finger flap for coverage of soft tissue defects onvolar side of fingertip with bony exposure.

Four patients in our study underwent First DorsalMetacarpal Artery Flap for coverage of thumb defectswith successful outcome. Sherif MM (18), reviewedseventy-nine cases of first dorsal metacarpal artery flapsfrom dorsum of index finger in various situations. In thisstudy, 4 patients required thenar flap cover for pulpreconstruction. 2 patients had joint stiffness in post opperiod which was managed by physiotherapy.

Melone CP, et al (19), reviewed one hundred and fiftyconsecutive cases of thenar flaps in patients with fingertipinjuries. Only six patients had joint stiffness. Deepithelized cross finger flap was employed as mode ofreconstruction in four cases of fingertip injury with dorsal

1. Jacques M. Kite flap in reconstruction of distal thumb,Fingertip and Nailbed injuries. Churchill Livingstone 1991.

2. Russel RC, Van Beek AL , Wavak P, et al. Alternative handflaps for amputations and digital defects. Am Jr Hand Surg1981;6:399-405

3. Hueston JT. Local flap repair of fingertip injuries. PlastReconstr Surg 1966;37(4):249- 350.

4. Lee LP, Lau PY, Chan CW. Local flap repair of fingertipinjuries. J Hand Surgery 1995;20:63-71.

5. Fattah JH, Awla RH, Zanco J. Fingure tip injuries. Med Sci2013;17:518-524.

6. Saaiq M. Profile of Finger Tip Injuries. Pak Inst Med Sci2009;5(3):131-35.

7. Saraf S, Tiwari VK. Fingertip injuries. Ind J Ortho2007;41:163-168.

8. Bernard SL, Boudreaux B. Hand anatomy and examination,Plast Reconstr Surg 2010;1:484-485.

9. Trybus M, Lorkowski L, Brongel L, et al. Fingertip injuries.Am J Surg 2006;192:52-57.

10. Das SK, Brown HG. Management of lost fingertips inchildren. Hand 1978; 10:16-27.

11. Lemmom JA, Janis JE, Rohrich RJ.Fingertip injuries. PlastReconstr Surg 2008;122:105-115.

12. Eberlin KR, Busa K , Bae DS, et al. Composite grafting forpediatric finger tip injuries. NY J Hand 2015;10:28-33.

13. Atasoy E, Loakimidis E, Kasdan ML, et al. Reconstructionof the amputated fingertip with a triangular volar flap-anew surgical procedure. J Bone Joint Surg 1970; 52A:921.

14. Freiberg A, and Manketlow R. The Kutler repair of fingertipamputations. Plast Reconstr Surg 1972; 50:371.

15. Fassler PR. Fingertip injuries: evaluation and treatment. Jr.Am. Acad. Orthop. Surg. 1996;4:84-92.

16. Edgerton BW, Beasley RW. Dorsal cross finger flaps. Grabb'sencyclopedia of flaps, Second edition 1998. LippincotRaven.pp.3456

17. Lee WP , Ganchi PA. Fingertip reconstruction. Plasticsurgery. Philadelphia. Saunders- Elsevier.2006.pp.153-154.

18. Sherif MM. First dorsal metacarpal artery flap in handreconstruction: II. Clinical application. Am Jr Hand Surg1994;19:32-38.

19. Melone CP, Beasley RW. The Thenar flap: Analysis of itsuse in 150 cases. J Hand Surg 1982; 7:291-297.

20. Al-Qattan MM. De epithelized cross finger flaps versusadipofascial turnover flaps for the reconstruction of smallcomplex dorsal digital defects: a comparative analysis. AmJ Hand Surg 2005;30:549-557

defects. Al Qattan MM (20) described the role ofdepithelized cross finger flaps for restoration of smallcomplex dorsal digital defects. Conclusion

Fingertip injuries are one of the most commonencountered injuries by the reconstructivesurgeon.restoration of function and maintainance of thedigital length are the primary goals of reconstruction.