Fingertip Amputations & Finger Flaps

Updated: Apr 14 2023

Mark Karadsheh MD

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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 AdvancementVolar 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 to75% 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

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