Digital Tip Injuries with Skin and Pulp Tissue Loss Only

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Distal fingertip amputations that are 1 cm2 or less in size without exposed bone can usually be treated conservatively in the ED with serial dressing changes alone. This is a desirable option, because healing occurs by secondary intention and results in very little scarring. Follow-up is arranged in 2 days for wound check and the patient is made aware that wound care is vital to the success of this technique. The patient is instructed to soak the injured fingertip in warm water to which an antibacterial soap has been added once a day for 10 min, followed by tap-water irrigation and application of a sterile nonadherent dressing. This procedure is performed daily for the first 10 to 15 days and every other day thereafter. On average, complete healing may take 4 to 8 weeks, and both the cosmetic appearance and sensibility of the fingertip are quite satisfactory with this technique. Conservative management is advocated in children less than 12 years of age, since they have greater regenerative potential than do adults.6 Loss of volume, lack of pulp firmness, and increased sensibility (particularly to cold) have been reported in approximately 30 percent of patients.7

In cases where the severed skin tip is available, an alternative means of treatment is to use the amputated portion as a full-thickness skin graft. The amputated tissue is cleaned and debrided of nonviable tissue, the undersurface of the skin is then defatted with sharp scissors and sutured to the defect using nylon sutures. Sutures are left long and tied over a 2- by 2-cm gauze stent dressing to compress the graft firmly against the fingertip. Appropriate follow-up is made and unless obvious purulence ensues, the stented dressing is left undisturbed for 7 to 12 days.

A split- or full-thickness skin graft harvested from a distant site is another means of wound closure. This procedure may be indicated in situations where the severed skin tip is either not available or nonviable, significant pulp tissue loss is greater than 1 cm 2, or the patient's desire to have full use of the hand precludes waiting the 4 to 8 weeks necessary for healing by secondary intention. In these cases, consultation with a specialist is appropriate. Most surgeons recommend using the hypothenar eminence of the injured hand as the donor site, since the skin from this region is the same type of glabrous skin as is present on the fingertips. 1 The graft is left in place for 7 to 12 days and allows for rapid wound closure and healing. Complications with skin grafts include decreased sensibility of the fingertip, scar tenderness both at donor and graft sites, cosmetically poor quality of coverage, and hyperpigmentation in patients with dark skin. 7

Many authors agree that conservative management of fingertip injuries without bone exposure, as opposed to the above techniques, is superior in terms of cosmetic appearance, improved function, and sensibility of the involved digit. I6.,8

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