Digital Tip Injuries with Exposed Bone

If a significant loss of tissue to the fingertip causes exposure of the tuft of the distal phalanx, skin grafting will be unsuccessful since bone does not provide adequate vascularity to support the donor tissue. Several treatment options exist, always keeping in mind the important goals of preserving digit length, especially with regard to the thumb and index finger, as well as sensitivity and functionality of the fingertip. The size and geometry of the injury, the angle of tip amputation, and the availability of the amputated tip will determine the options available for wound closure.

If the bony protuberance is less than 0.5 cm in length and the soft tissue defect is less than 1 cm 2, the bone may be trimmed back using a rongeuer and the wound left to heal by secondary intention as previously described. A dorsal obliquely angulated wound ( Fig, 3.9-2..D) may be treated in the ED with bone shortening followed by primary closure of the wound using the adjacent volar tissue. An injury of this type has a favorable prognosis because the sensate volar skin is intact. Fat from the local tissue may need to be trimmed to allow wound closure without tension. The nail should be removed and attention paid to associated injuries to the nail bed and surrounding structures. Although results are comparable to those following conservative management, shortcomings include loss of length as well as tenderness of the fingertip and some degree of functional disability.

FIG. 39-2. Fingertip amputations. A. Volar angulation without bone exposure. B. Volar angulation with bone exposure. C. Transverse or perpendicular angulation with bone exposure. D. Dorsal angulation with bone exposure.[From Russell RC: Fingertip injuries, in McCarthy J (ed): Plastic Surgery. Philadelphia: Saunders, 1990, p 4479, with permission.]

Amputations that are angled either in a transverse or volar direction ( Fig 39:26 and Fig.i39-2C) have less favorable outcomes because they do not always have adequate soft tissue and skin coverage to allow for primary closure and preservation of length. Consultation with a plastic or hand surgeon is necessary, as these injuries often require the use of sophisticated local V-Y advancement or adjacent pedicle flaps to maintain length and provide tissue coverage, a technique beyond the scope of practice by most emergency physicians.

Incomplete digital tip amputations, defined by the retention of the neurovascular bundle as well as portions of the underlying bone, may be replaced as a composite graft. However, as reported in the literature, these are among the most difficult injuries to reconstruct and require consultation with a specialist. If adequate circulation is retained in the tip, the injury is treated with fracture reduction, internal pin fixation, and repair of the soft tissue injury. This procedure is optimally performed in the operating room.

In all patients with a complete amputation that occurs proximal to the lunula, consultation with the hand or plastic surgeon is recommended for possible replantation in the operating room. Conversely, in the adult patient, replantation of a complete amputation distal to the lunula is not usually advocated. This is because the procedure is technically demanding owing to the arborization of the neurovascular bundle at this location, and it carries a poor prognosis. However, consultation with the surgical specialist is clearly indicated in all patients with specific occupational concerns and when the injured digit is the thumb or index finger.

Although fingertip injuries are quite common in children, most require only conservative management because of the rapid healing process. Repairs should be done using absorbable sutures. Surgical procedures such as grafts and advancement flaps should be avoided where possible. A completely amputated composite tip may be reattached to serve solely as a biological dressing, and parents should be informed that the tip might necrose, dry up, and turn black as the underlying wound continues to heal. However, in children less than 6 years of age, replantation and revascularization of the composite tip may be a viable treatment option performed by the surgical specialist.

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