Retaining the articular cartilage in finger joint amputations.

RETAINING
THE ARTICULAR
CARTILAGE
FINGER JOINT
AMPUTATIONS
LIN’I
¯ " O~
N A. \VHITAKER, M.D.,
V~zAYNEH. RISER, I).V.M,
IN
WILLIAM P- GRAHAM,III,
M.D.,
A~I) EUGENEKILGORE, M.D.
Philadelphia, Pa.
At operation, the significant
ligated with 5-0 chromiccatgut and
wounds were closed with a continuom
o[ 5-0 nylon. A gauze bandagewas
pad and taped in place. All wounds
marily without evidence o~
Following sacrifice of the animals
designatedtimes (two, 4, 6, and
forelegs weredisarticulated at the
and submitted ~or radiographic
study. The skin of the first pair was
but it wasleft on the remainder.
Specimenswere prepared for
amination by first shaving and then
the remainderof the hair with a chemi
atory. Theentire foreleg wasthen:
1. placed in 15%~ormic acid
ously agitated until decalcification
usually within about two weeks;
2. split into twohalves with a
makea sagittal section;
3. dehydrated with alcohol and
xylol;
EXPERIMENTAL
METHOD
4. embedded
in paraffin;
5. cut with a microtomeinto
The left forepaws of 8 young cats were ments(with a sagittal cut orientation);
6. stained with hematoxylinand
amputated. In 4, the disarticulation
was
between the proximal carpal row and the mountedbetweentwo glass slides.
This methodallowed gross and
radius-ulna; in the other 4, the amputavisualization and comparison.Sectiola!
tion was done at the same level, but the to be representative of each time
articular cartilage was entirely removed chosenfor analysis.
by rongeur from the distal ends of the
X-RAY FINDINGS
radius and ulna. One cat from the disarticulated group, and one from the disThere was slight
articulation
plus chondrectomy group,
rounding off of the bones,
killing of the first animals (two
were killed at two, 4, 6, and 8 months.
One cat in the disarticulation
,.plus
and the last (8 months).
chondrectomy
group died within one
and smoother ends were visible
month, leaving
only 7 in the study
disarticulation,
specimens; the
group. Thus, only the disarticulation
plates were absent in the
animal was available for the 8 months plus chondrectomy sp~
observation,
In amputations of the upper extremity, conservation of length is the rule.
However, if amptttation
is through a
joint, excision of the articular cartilage
has been advised--ostensibly
to allow
the soft tissues to gain a firm attac]hment to the bone and to avoid possible
sequestration of the cartilage after degeneration? -a Some have stated that tbfis
same attachment will eventually
occur
if the cartilage is left in place, but only
with a risk of possible chondritis
and
sequestration. °- We have felt, from our
clinical experience, that leaving as much
articular cartilage behind as possible in
transarticular
amputations is actually the
best method. The following experiments
were done to test this.
Fromthe Hospital of the University of Pennsylvania and the Harrison Department of Surgi.cal 1
Presented at the Annual Meeting of the American’ Society of lZlastic and ReconstrucUv¢
October 4, 1971 in Montreal, Canada.
542
Vol../9,
GROSS
,ificant bleeders were
catgut and the skin
a continuoussuture
dage was applied as a
~11woundshealed prior complications.
the animals at the
6, and 8 months),the
ed at the elbow joint
aphic and microscopic
rst pair was removed,
tinder.
¯ ed for microscopicex. "
,g and then removing
with a chemicaldepil.
.vas then:
nic acid and contlnu.
calcification occurred,
weeks;
s witha razor blade to
lcohol and placed in
~n;
~meinto about 10 seg.
orientation);
:oxylin and eosin, and
tss slides.
gross and microscopic
rison. Sectionsthought
each time period were
INDINGS
t maturation
and
bones, between the
limals (two months)
~ths). Growth plateS
,-ere visible in all the
imens; the
n the disarticulati0n
pecimens(Fig. 1).
at of SurgicalResearch.
econstructiveSurgeons
No.
5
/
CARTILAGE
AND
MICROSCOPIC
IN
JOINT
AMPUTATIONS
543
FINDINGS
Two Months, Disarticulation
Only
Remnants of the joint capsule (with
villi and synovial cells), and the connective tissue contiguous with the joint
capsule, were present. They formed :a
pannus which, at the point of fusion, appeared to be fibrocartilage
sealing the
end (Fig. 2).
The articular
cartilage had degenerated, with a change in staining reaction
peripherally,
from the normal basophilic
to eosinophilic.
The cartilage present
showed changes ranging from normal
nuclei with abnormal cytoplasm (in the
outer two-thirds of the cartilage) to abnormal, pyknotic nuclei (in the proximal
0he-third, next to the subchondral plate).
In the proximal one-third, smearing and
several pseudo-tide lines paralleled the
Fro. 1. X-rayfilms of (le[t) disarticulation only
articular cartilage; the subchondral bone
and(right) disarticulation plus chondrectomy
speci.
was indistinct
and irregular.
(These
mensfromcat. At the bottomone can see that the
changes were all consistent with inadegrowthplate and a smootherend is present in the
disarticulated specimen, comparedto no growth
quate cartilaginous
nutrition--normally
supplied by the synovial fluid produced plate and the roughend of the disarticulation plus
chondrectomy
specimen.
by the joint capsular structures of the
opposing joint surfaces.)
A few round present in the adjacent connective tissue.
cells were scattered between the layers
Necrotic metaphyseal trabecular
ends,
of connective tissue, but there was no
adjacent
to
the
line
of
chondrectomy,
significant inflammation or fluid accumu- were present--as
occurs with all fraclation (Fig. 2).
tures. There were nulnerous osteoclasts.
Two Months, Disarticulation
plus Chondrectomy
The epiphyses and growth plates had
been cut away, along with the ,joint capsule, leaving a surface of irregular and
blunt ends of metaphyseal trabeculae
(Fig.3).
Active remodeling was in progress,
with connective tissue encasing the exposed trabeculae and sealing off the martow spaces. Newly formed fibrocartilage
and bone had been laid down on the
trabecular and surface ends.
Necrotic bone chips, indicated by absence of osteocytes in the lacunae, were
(All this was evidence of considerably
more remodeling occurring in the disarticulation
plus chondrectomy specimen
than in the disarticulation
specimen.)
Numerous round cells
were present
throughout all layers, but with no collectiorl into focal areas of inflammation
(Fig.
Four Months, Disarticulation
Only
The fibrous tissue had decreased in
amount, and there was a more normal
and healthy appearance--including
the
presence of normal-appearing fat cells in
the connective tissue interstices.
The remaiuing ~artilage
had narrowed, and
544
IaLASTIG & RECONSTRUGTIVE SURGERY,
l~IO. 2. Gross and microscopic appearance of a disarticulation
only specimen, after
months, a = fibrocartilaginous
pannus, present over the end; b = round cell infiltration;
absence of inflammation; g __~ continuous osteocartilaginous cortex.
May 1972
two
c =
F~c. 3. Gross and microscopic appearance of a disarticulation
plus chondrectomy specimen,
after two months. The irregular and discontinuous trabecular ends (d) are covered by thick
fibrocartilage (a). Nmnerousnecrotic bone chips (e), osteoclasts, and round cells are present.
There is more evidence of active remodeling than in the disarticulation
only specimen.
cells were now dead distal to the tide line
throughout the articular
cartilage.
The
pseudo-tide lines had all disappeared; a
single heavy tide line remained. Again,
there were a few inflammatory cells, but
in a decreased number compared with
the previous specimens (Fig. 4, left).
Four Months, Disarticulation
plus Chondrectomy
There was considerable fibrous tissue
over the stump end. A discontinuous
bony cortex was now present, with trabecular, fusion. Active remodeling with
multiple osteoclasts was still in progress;
the ti
cells
chon(
bony
round
lation
chondr,
generally,
and chang
matory r(
throughou~
the sam~ a
men(Fig.
]i~.GERY,
May1972
uen, after
nfiltration;
two
c =
ctomy specimen,
:overed by .thick
ells are present.
specimen.
545
VoI. 4P, No. 5 / CARTILAGE
IN JOINT AMPUTATIONS
F~G. 4. (lelt) Disarticulation only specimen,, after 4 months. A fat pad (J) is present within
the fibrous (a) layer over the end. Only a small amount of cartilage (b) remains. Rare round
cells (c) are present. Cartilage is being replaced by new bone. (right) Disarticulation
plus
chondrectomy specimen, after 4 months. Note the thick fibrous layer (a), the discontinuous
bony cortex (g), absence of any fat pad, the several osteoclasts present, and the persistence of a
round cell infiltrate (c). There is more evidence of continued remodeling than in the disarticulation only specimen.
FIG. 5. (left) Disarticulation only specimen, after 6 months. (right)
chondrectomy specimen, after 6 months. See text for description.
Disarticulation
plus
dation plus Chow
.~ble fibrous tissue
A discontinuous
present, with tra¯ remodeling with
ts still in progress;
generally, considerable tissue activity
and change were evident.
The inflammatory response
was again present
throughout all layers, probably about
the same as in the disarticulated
specimen(Fig. 4, right).
Six Months, Disarticulation
Only
A fat pad was present over the end of
the stump, within the fibrous tissue. All
cartilage
had been replaced except a
small ar~a in the middle portion of the
articular surface and subchondral plate.
PLASTIC & RECONSTRUCTIVEsURGERY, .May 1972
546
oclasts, and a discontinuous bony cortex
were present. There was persistent round
cell infiltration in all fibrous layers (Fig.
5, right).
In this central area, cartilage was present
only proximal to the tide line. A narrow
layer of periosteal-like
tissue, continuous over the periphery and similar to
that developing in the 4-month disarticulation
phls chondrectomy specimen,
was present. Scattered round cells were
present, the only indication of inflammation (Fig. 5, le[t).
Six Months, Disarticulation
drectomy
Eight Months, Disarticulation
Only
The articular
cartilage
had disapPeared entirely, with only the bone of the
subchondral plate remaining; a periosteal-like tissue was continuous over the
surface of the underlying bone. Less,
but continuing, remodeling was in progress.
(As noted, there was no "Disarticulation plus Chondrectomy" specimen available at this period.)
plus Chon-
A thick fibrous tissue layer was present, with no fat pad. All other features
were similar to the specimen at 4 mon~ths;
continuing remodeling, with several oste-
Dis a
pres,
laew
prog
ing ~
resp,
mon
been
Disa
R~
mOlll
~wi
covel
I
I
osteo
infilt
over
disar~
much
ampu
all b~
WaS :
Fro. 6. Finger disarticulations in our clinical series of patients. (lelt) Numberdisarticulated
at each joint. (center) Removalof lateral[ flare. (right) Removalof palmar bulge.
Fro. 7. One of the patients, brought in after traumatic amputations of the ring and long
fingers. (lelt) The long finger amputation was at the distal joint; bere, the lateral flare of the
distal end of the middle phalanx is behag removed with a rongeur. (center, right) Appearance
several months later. The articular cartilage was left on the stump of the long finger, but removedfrom the s:ump of the ring finger. The patient felt that the long finger stump was quite
comfortable.
The photographs do not demonstrate any significant
difference between the
results.
volve,
carpo
geal, z
all di:
thuml
Six p;
than ~
Wh
ering
am pu:
only ~
phala~
ronge~
move(
a bu] t
70 per
S~RGERY,May 1972
nuous bony cortex
as persistent round
fibrous layers (Fig.
:culation
Only
tilage had disap,nly the bone of the
emaining; a peri¯ ontinuous over the
flying bone. Less,
deling was in progas no "Disarticulany" specimen avail-
nber disarticulated
!ge.
the ring and long
lateral flare of the
¯ right) Appearance
long finger, but refer stump was quite
¯ fence between the
Vol. 49, No. 5
/
CARTILAGE IN JOINT AMPUTATIONS
547
be left on the stump.) An operative view
of the lateral ttare of cartilage being removed, and the end result in the same
Disarticulation
Only
?atient, are shown in Fignre 7.
Articular cartilage degeneration was
In this series, there was no infection,
sequestration,
or other form of delayed
present at two lnonths postoperatively,
Six
with fibrous tissue formatiou distally and healing; none required revision.
other fingers in this series, with convennew bone proximally.
This continued
progressively with an end fat pad becom- tional amputations, likewise required no
revision and healed without complicaing apparent, but minimal inflammatory
response and no sequestration.
By 8 tions. Bnt we believe that those with the
months all the articular
cartilage
had disarticulated
fingers generally had a
~nore flexible and less fixed stump scar,
been replaced.
and a more comfortable stump. This imDisorticulation
phts Chondrectomy
pression was confirmed by several paRemodeling was very active at two tients who had both types of amputations
months, and was still active at 6 months simultaneously. In addition, this method
~with a relatively
heavy fibrous tissue
produced less bleeding, the surgery was
cover,
all incomplete cortex,
nmnerous
simplified, and it preserved more length.
osteoclasts, and a pronounced round cell[
Therefore, while the appearance of the
infiltration.
fingertips
postoperatively
often showed
no significant difference (as in the case
CLINICAL CASES
depicted) we believe this method to be
Twenty male patients,
ranging in age preferable--for the reasons given above.
from 17 to 63 years, have been treated[
SUMMARY
over the last 5 years by transarticular
disarticulation,
with preservation of as
In transarticular
aInputations of the
much articular cartilage as possible. All fingers, it has been customary to surgiamputations were traumatic in origin;
cally remove the articular cartilage. Here
all but two occurred while the patient:
we present experimental and clinical evwas at work. These amputations
in-.
idence to support our view that it is betvolved, at one time or another, the meta- ter to leave the articular cartilage on the
carpophalangeal, proximal interphalanend of the stump.
geal, and distal interphalangeal joints of
Linton A. Whitaker, M.D.
all digits--except
the M-Pjoints of the
Department of Surgery (Plastic)
thumb and long fingers (Fig. 6, left).
3400 Spruce Street
Six patients have had injuries
to more
Philadelphia, Pa. 19104
than one finger.
Dr. Kilgore is at the University of California
Where sufficient local soft tissue covering was available, and the level of the School of Medicine in San Francisco.
amputation made it appropriate to do so,
REFERENCES
only the lateral or palmar flare of the 1. Flatt, A. E.: The Care o] Minor Hand Injuries,
phalanx (with its overlying cartilage) was
p. 159. C. V. MosbyCo., St. Louis, 1959.
rongeured away (Fig. 6). Enough was re- 2. Tempest, M. N.: The emergency treatment of
digital injuries. Brit. J. Plast. Surg., 7: 153, 1954.
moved so that the digit was left without
a bulbous tip. (With care, perhaps 60 to 8. Slocum, D. B.: In Hand Surgery, p. 522. Edited
by J. Edward Flynn. Williams ge Wilkins, Balti70 per cent of the articular cartilage can
more, 1966.
SUMMARY OF "I’HE
EXPERIMENTAL
FINDINGS
~] Donot markthis box.t
Document:11000258
FINGERTIPINJURIES
so£t tissue only
volar pad
bone
nail + support for nail
REPAIR
NEE’D
durable sensible cover for bone
support for nall
restorationof length
satisfactoryappearance
open
graft (thickness,~donor site
flap - same digit (V-Y advancement,volar adv, dorsal, flag)
-’elsevhere(cross finger, thenar)
innervatedflap
GRAFT DONOR SITES vrlst crease, hypothe~ar, groin, forearm
CHOICE OF METHOD
TIMING
age, work requirements,nature of Injury, compensation
delayed primary repair
KISS,
NAIL INJURIES
Clavburgh:
McCash:
"significant trauma {to the germinal matrix] obviates repair
of the distal portion of the nail bed."
"The tips of the fingers in man represent the tactile horizon of
the body."
" Apart from the value of the nails in relation to the rest of the
body, their cosmetic importance remains the chief indication for
our efforts:as plastic surgeons to find a satisfactory techniaue
to restore them:"
1938
Barrett Brown reported replacement of amputated nail matrix and a little
bit of tip skln with complete take a~nd normal nall appearance
Buncke:
"Measles ~s one of the few sy~temlc illness which has an arresting
effect on nail growth, even more profound than that of death, but
not as permanent."
Nail functlo~s
Buncke 3 instruments for scratching a~nd picking plus lending support
and protection to the tactile pad of the fingertip
Zook - protects fingertip; may alsoplay a part in tactile sensation
of the tip; adds to delicate and precise touch, skilled hand
function and ability to pick u!p tiny objects
Verdan:
"The epidermis under the nail is able to build a corneous
substance which is responsible for the extraordinary adherence
of the nail to its bed."
(5) Fillet
(6) Muscles
(a) Brachioradialis
(b) ECRL
(c) FCU
(d) ECU
(e) Pronator quadratus
(f) Abductor digiti minimi
(7)Reversed radial forearm
(8) Reversed posterior interosseous
no
artery -- PIA
Distant flaps
1. Random
a. Examples
(1) Cross arm
(2) Chest
(3) Abdominal
2. Axial
a. Pedicle
(1) Groin
b. Free (by microvascular transfer)
(1) Examples
(a) Scapular (cutaneous)
(b) Lateral arm (fascial)
(c) Tailored latissimus dorsi (muscular)
(d) Radial forearm
Fingertip
I. Introduction
A. Most common hand injury
¯ B. Most sophisticated
organ of touch
C. Injury may lead to significant
II.
disability
Anatomy
Figure3
1’9:3
A. That portion of the digit distal
to the insertions
B. Volar pulp covered by highly innervated
of the extensor and flexor tendons
skin
C. Skin anchored to phalanx by fibrc~septae
D. Nail and nail bed
III.
Goals of Treatment
A. Adequate Sensation
,B. Minimal tenderness
C. Satisfactory
appearance
D. Full joint motion
E. Maximumlength
IV. Factors
consistent
with above goals
in Choice of Treatment
A. P~tient
I. Age
2. Occupation
3. Digit involved
4. Sex
Algorithm for Selection
of Treatment of Fingertip
n. REPAIR
tissue loss? NO . untidy?~N,.,--
DEBRIDE
bone exposed?~ contacll NO----SPLIT SKIN
surface’?
[ YES
YES [
FULL THICKNES!~SKIN
moreloss
palmar?
NO . ADVANCEMENT
FLAP
YES1
young
patient?
NO ~ RI-’VISIE
YES1
finger?
or small loss?
YES~
NO
PRIIVIARY
NEUROV~.SCULAR
ISLAND
NO ,. TH["NAF|FLAP
male?
YES~
CROSSFINGERFLAP
Figure4
19-4
Injuries
I3. Nature of defect
1. Size and location
2. Mechanism of injury
-a. Sharp
b. Crush
c. Avulsion
3. Bone exposure or not
4. Angle of loss
Treatment
Methods
A. Open--healing by wound contraction and epithelialization
1. Indications and advantages
a. Children
b. Adults with defects 1 cm or less
c. Simple procedure
2. Technique
,,
a. Thorough cleansing
b. May need to shorten bone (always eq~aal nail bed)
c. Dressing change at three to five days
d. Daily dressing changes until healed
3. Disadvantages
a. Prolonged healing
b. Stump tenderness
B. Replacement of amputated part
1. Composite graft
a. Indications and advantages
(1) Children
(~) Distal tissue
(3) Sharp amputation
(4) Best appearance when successful
b. Disadvantages
(1) Unpredictable
(2) Recovery delayed by failure
2. Microv~scular replantation
a. Indications and advantages
(1) Level just distal to DIP joint
(2)Outpatient
procedure
(3) Best apl)earance
(4) Potential for useful sensibility and ~aeuroma prevention
b. Disadvantages
(1) More prolonged surgery
(2~Expense
C. Primary closure with shortening
t. Indications and advantages
a. Loss of over 50% of the distal phallanx
b. Irreparable damage to nail matrix
c: One stage procedure
d. Early immobilization and desensitization
19-5
(important in older or stiffer
hands)
2. Technique
Figure 5
a. Trim bone to achieve tension-free closure
b. Always trim nail bed as far proximal as bone
c. Neurectomy
~
(1. "~nsion-free closure
3. Disadvantages
a. Digital shortening
b. May develop painful neuroma
D. Skin graft
1. Split-thickness graft
a.-Indications
and advantages
(1) No bone exposed, sites with less contact
(2) Graft shrinkage reduces size of defect
b. Technique
:
(1) Prepare recipient site
(2) Choice of donor site (side of pro.×imal phalanx or hypothenar eminence)
(a) Donor site scarring
(b) Color and texture match
(3) Attach graft
(a) Sutures
(b) Tape strips
19-6
c. Disadvantages
(1) Wound coverage may be
(a) Unstable
(b) Dysesthetic
(c) Unsightly
(2) Donor site scar may be objectionable
2. Full-thickness skin graft
a. Indications and advantages
(1) No bone exposed, sites with more contact
(2)More durable coverage
(3) Direct closure of donor site
b. Disadvantages
(1) More difficult "take"
E. Local flaps
1. V-Y Advancement
a. Lateral (Kutler)
b. Palmar (Atasoy)
c. Indications and advantages
(1) Transverse (Atasoy) and dorsal oblique amputations (Kutler)
(2) Good sensation; minimizes sensitivity
d. Technique
S
Figure 6
(1) Single palmar V-¥ (Atasoy)
(2) Outline palmar triangular flap
(a) Width equals width of nail
(b) Length: apex based at distal
(3) Loupe magnification
(4) Incise skin and dermis
19-7
interphalangeal
joint flexion crease
~
(5) Divide septae
(6) Separate flap from palmar surfa(~e of distal phalanx periosteum and terminal
flexor tendon
(7) With small, fine scissors separate the V limbs of the triangle to identify and
divide fibrous septae
(8) Differentiate
septae from vessels and nerve by examination under loupe
magnification
(9) Remember
(a) Vessels and nerve--elastic
(b) Fibrous septae--inelastic
(10) Advance and suture flap
(11) Release tourniquet
(12) Double lateral V-Y(Kutler)
D
Kutlerdouble
lateral V-Yadvancements.
(~.) Theadvancement
flapsaredesigned
overtheneurovascular
pedicles
andcarriedrightdown
to bone
(B). Thefibrousseptae
aredefiend
and(¢) divided,
permitting
mobilization
(D)ontheneurovascular
pedicles
alone.Theflapsthenadvance
readilyto themidline
(E).
Figure 7
(a) Location of apex--may locate proximal to DIP crease
(b) Anterior incision through skin only
(c) Mobilization--through dorsal incision divide septal connections between flap
and periosteum
Through
palmar incision as in palmar V-Y advancement, carefully identify and
03)
release fibrous septae, preserving more elastic vessels and nerves.
(14) Round off distal contour of amputated bony stump (not proximal to nail bed)
(15) Advance radial and ulnar flaps created to meet in midline
(l 6) I)isadvantagcs
(a) Technically demanding
(b) Limited tissue available
19-8
2. Pahnar advancement flap (Moberg)
A
Figure 8A\
r/
A
B
Figure 8B
a. Indications and advantages
(1) Only for thumb (Macht and Watson, 1980)
(2) Maycover up to 1.5 cm palmar defect
(3) Near normal sensibility
b. Technique
(1) Midlateral incision, dorsal to neurovascular bundles
(2) Careful mobilization of flap based upon neurovascular bundles
(3) Advancement(helped by flexion of interphalangeal joint)
(4) ? proximal transverse incision and FTSGon secondary defect
3. Disadvantages
a. Flexion contractures
b. [)otential for dorsal tip necrosis if neurovascular bundles injured
19--9
Regional flaps--adjacent digit or pahn
1. Cross finger flap
a. [n(lications
and advantages
(I) Covers large defects
(2) Versatile and reliable
(3) Maybe innervated (tIastings)
b. "Ibchnique
F
It canbe seenthat this approximatesthe flaps to ’the defects with full
closure of the bridge segment.(I =) This is showndiagrammatically.
Figure 9
(1) Prepare recipient area
(2) Design flap from a(ljacent digit (usually middle phalanx)
(3) Raise flap and suture in place
(4) Split- or full-thickness coverage of donor defect (over graft pedicle)
(5) Release and inset at two to three weeks
Disadvantages
(1) Potential for joint stiffness in both digits (possibly more)
(2) Creates defect on normal digit
(3) May be hair-bearing
(4)Scar of secondary defect unacceptable in women
19-10
2. Thenar flap
Figure 10
a. Indications and advantages
(1) Children and young adults (especially women)
(2) More subcutaneous fat avai]lable than cross finger
(3) Good color and texture match for pulp
(4) Donor site can be closed priimarily, but rarely
b. ~l~.ch ni(]ue
(1) Prepare recipient site
~ (2)Design and elevate thenar flap ~(50% wider than defect to recreate
(3) Close donor defect
(a) Graft
(b) Suture if in thenar crease
(4) Suture flap in place
(5) Detach at two weeks
c. Disadvantages
(t) Potential for joint stiffness
(2) Limited size of flap
19-11
pulp)
¯ VII.
A
Summary
_
1. Open treatment
2. Fr.. g~’aft
I
.
B
1. Shorten and close
2. Mlcrovascular raplantatlon
"
-1
~~:
C
1.
2.
3.
4.
Cross finger flap
Thenar flap
Double lateral V-Y
Free graft
:
1. VoY advancement flap
2. Yolar advancement flap
3, Free graft
I~;
k~,’.:;.-:~~
’~
-
Figure 11
Nail
and Nail
I. Importance
Bed Injuries
of Nail
A. Support of pulp
1. Sensibility
2. Protection
3. Fine manipulation
B. Appearance of finger
II. Types of Injury
A. Subungual
hematoma
B. Avulsion of nail matrix from nail fold
C. Nail bed laceration
D. Loss of nail matrix
III.
Principles
of Treatment
A. Remove nail
if undermined by large
subungual
hematoma
B. Repair nail bed laceration
C. Replace nail if possible to prevent; na.i[1 fold and S~lint
D. Graft nail bed defects with split-thickness
1. Adjacent uninjured nail
2. Toenail
E. K-wire distal
phalanx if unstable
Figures 1, 2, 7, and 9 repr,)duct’d
Livingstone, 19~P,.
nail bed graft
wilh permission from Green, I)P: Opm’alit’c I/and S ~r.t/t’r?l,
Seco/~tl Edilion,
NewYnrk, Chm’chill
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