FINGER TIP INJURIES in hand ( plastic surgery).pptx

finger tip injuries management

1. FINGER TIP INJURIES

2. INTRODUCTION Frequently encountered - Why? Different mechanisms – sharp cuts/ fall of heavy objects/ RTA’s, machine entrapment/ burn injuries.

3. anatomy Four main components Nail Pulp Distal phalanx Tendons – flexor and extensor

4. objectives Maintain length Restore sensation Provide stable soft tissue coverage Prevent symptomatic neuromas Prevent adjacent joint contractures Allow early return to activities of daily living Allow early prosthetic fitting when applicable

5. Finger tip recon - principles Irrigation of wound Debridement of devitalised tissue Fixation of distal phalanx fracture Nail bed repair Soft tissue cover Replace like with like

6. classification

7. Nail bed injuries SUBUNGUAL HAEMATOMAS Small clots – small hole with needle Larger – need drainage by lifting or removal of nail plate.

8. Nail bed laceration Mechanisms : crush injury/ sharp injury Repair under anaesthesia and torniquet Minimal debridement Preserve maximum nail bed tissue Repair with 6-0/7-0 absorbable monofilament/ monocryl Severe crushing injury – nail bed graft from toe

9. Reconstruction ladder Secondary healing Skin graft STSG FTSG FLAPS Local Regional distant

10. Wound healing – secondary intention Indication – small areas , no tendon exposure For areas < 1cm 2 If >2-3cm 2 , takes 4-6 weeks to heal Advantage – avoids surgery, no secondary donor site scar Disadvantage – requires more time to heal, unstable scar -hypersensitivity

11. Skin graft Indications – when only minimal tissue loss at tip Types STSG FTSG Composite graft of amputated part

12. ADVANTAGES Avoids regular dressings Good sensory recovery FTSG>STSG Good aesthetic outcome DISADVANTAGE No contour correction in case of tissue loss Not a match for glabrous skin of palm

13. Composite graft Amputed finger – has fatty tissue with septae / glabrous skin/part of nail bed Used as composite graft after defating Good aesthetic and sensory recovery Best results in children below 10year of age. Biological dressing. Healing underneath gives adequately contoured fingertip.

14. Local flaps Rely on rich vascular supply of finger tip ADVANTAGES good aesthetic outcome Glabrous skin restored Good functional and sensory recovery DISADVANTAGES Insufficient for large defects

15. Commonly used local flaps ATASOY KUTLER VENKATSWAMY CROSS FINGER FLAP

16. ATASOY – KLINERT SKIN FLAP INDICATIONS Dorsal oblique – best Transverse amputations C/I – Volar oblique amputations

17. REQUIREMENTS Digital block anaesthesia Surgical loupe for magnification torniquet

18. OPERATIVE TECHNIQUE - ATASOY DEBRIDEMENT Soft tissue on stump Skin edges Nail bed remnant Protruding bone

19. FLAP DESIGN AND DIMENSIONS BASE – edge of amputated nail APEX – DIP Crease SIDES – gentle curved

20. KUTLER SKIN FLAP TRIANGULAR LATERAL V-Y SKIN FLAP IDEAL INDICATION Transverse guillotine amputation More proximal transverse amputations – where further shortening is not indicated.

21. VENKATASWAMI FLAP OBLIQUE TRIANGULAR SKIN FLAP TO THE FINGERTIP INDICATION : volar oblique > dorsal oblique Palmer skin and subcutaneous tissues superficial to fibrous flexor sheath Blood supply – NV bundle on the side of the finger

22. FLAP DESIGN AND DIMENSIONS

23. Insert video

24. CROSS FINGER FLAP For oblique volar defects Donor site : adjacent digit – distal to PIPJ Easy to harvest ; reliable anatomy Always requires a 2 nd stage procedure Immobilization risks stiffness of both digits Requires skin graft cover at donor site

25. DONOR FINGER ?

26. FLAP MARKINGS?

27. END POINT OF PEDICLE? Volar to mid axis – reduce the kink FTSG HARVEST – medial arm/forearm/ wrist crease

28. TECHNIQUE OF HARVEST

29. FLAP HANDLING Tension free inset – flexion of recipient digit at PIPJ Immobilization – proximal stitch Division – 2-3 weeks COMPLICATIONS Inadequate debridement Wrong plane of harvest Too long/ too short flap Cautery at base of flap Kinking of base

30. Modifications of cff IN DESIGN PROXIMALLY BASED DISTALLY BASED CF ADIPOFASCIAL IN TECHNIQUE REVERSE DERMIS CFF

31. MOD. IN DESIGN PROXIMALLY BASED CFF Ideal for distal soft tissue defects Dorsolateral aspect of finger ( MF/RF) Ulnar side of IF/ radial side of LF Defect at level of PIPJ or proximal to it Distal most margin - DIPJ Length – such that it can be transposed comfortably

32. PROXIMALLY BASED CFF ADVANTAGES – good quality of skin provided DISADVANTAGE - Longer flap required to comfortably transpose it.

33. DISTALLY BASED CFF Similar to proximally based CFF Defect distal to PIPJ on dorsolateral aspect Limited arc of rotation

34. CROSS FINGER ADIPOFASCIAL FLAP Marked just like classical CFF Base of flap on the contiguous side with injured finger But dermal flap raised first – opposite side

35. Soft tissues covering the extensor paratenon are raised as an adipofascial flap

36. Second stage – just as classical CFF ADV. Skin graft required only the adipofascial tissue Cosmesis better as skin graft only on injured finger ( unlike a reverse CFF DISADV. Adipofascial layer – delicate , careful elevation required. Graft take is not optimum over Adipofascial flap.

37. Mod in technique REVERSE CFF Skin on proposed area of flap de-epithelialized. After de- epithelialization Flap raised similar to classical CFF, superficial to ext. paratenon

38. REVERSE CFF ADVANTAGES Simple provedure More robust than adipofacial CFF, as it has dermis DISADV. Larger skin graft required. Poor cosmesis.