FINGERTIP INJURIES ARE THEY REALLY THAT SIMPLE? SANJAY K SHARMA, MD, FACS INSTITUTE OF RECONSTRUCTIVE PLASTIC SURGERY

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1 FINGERTIP INJURIES ARE THEY REALLY THAT SIMPLE? SANJAY K SHARMA, MD, FACS INSTITUTE OF RECONSTRUCTIVE PLASTIC SURGERY Austin Trauma and Critical Care Conference 2018 May 31-June 1, 2018

2 Outline 1. Scope of problem 1. Stats 2. Anatomy 3. Case vignettes 1. Crush 2. Nail lac 3. Burns 4. Mallet 5. Jersey finger Solutions DO nothing Skin graft Local flaps Distant flaps Not going to discuss Nail infections Abnormal nails Infections of fingertips

3 Our hands/fingers

4 Scope of the problem

5 Scope of the problem

6 More like this

7 Incidence of Hand Trauma 2015 National Center for Health Statistics 137 million visits 39 million Injury related Upper Extremity 16% = 6.25 million 2011: Wrist/Hand/Finger 9.1% = 3.55 million Upper Extremity 18.3% = 7.39 million Wrist/Hand/Finger 11.3% = 4.53 million National Hospital Ambulatory Medical Care Survey: 2015 Emergency Department Summary Tables

8 Goals of treatment Restore Closed wound Protective sensation, painless Functional digit Complications to avoid Nail deformities Painful neuromas Insensate or unstable soft tissue

9 Anatomy Germinal matrix Sterile matrix Eponychium Paronychium Lunula Pulp

10 Anatomy Function of nail Counterforce for pinch Contributes to tactile sensation Picking

11 Nailbed injury Common mechanisms Door Tools Crush working Crush working out Drill accident Saw Nail gun

12 Injury workup Detailed History Mechanism of injury Detailed exam Noting level of finger injury Nail involvement X-rays Comfort Local digital block: Marcaine YES--OK TO USE EPINEPHRINE

13 Nailbed Trephination Subungual hematoma 50% rule Release the pressure and allow nail to drain Can use cautery, needle Over time nail growth occurs at Glacial pace (3-6 months)

14 Burns Chemical: Hydro Fluoric Acid Scalding Electrical Burn

$No difference in outcome Stent the fold Place the nail plate back under Helps stabilize the sterile matrix Stabilize underlying fracture Will lift off over$

15 Repair If basic form is present, can do suture repair of laceration In children use absorbable sutures Nail bed injuries Suture repair Tissue Glue for nailbed No difference in outcome Stent the fold Place the nail plate back under Helps stabilize the sterile matrix Stabilize underlying fracture Will lift off over time

16 Open Fracture? Technically yes, open Rates % Infection Not Likely for common mechanisms of injury Crush, laceration, mechanical tools Clean, irrigated, stabilized <24 h Antibiotics? Tendency to No, but if going to treat should be less than 72 hours Prophylactic antibiotics in open distal phalanx fractures: systematic review and metaanalysis. Metcalfe D, Aquilina AL, Hedley HM. J Hand Surg Eur Vol May;41(4): Beware of these injuries Animal bites Human bites Seymour Fractures Contaminated, comminuted and multi-fragmented soft tissue injury Delay in presentation The High Risk of Infection With Delayed Treatment of Open Seymour Fractures: Salter-Harris I/II or Juxta-epiphyseal Fractures of the Distal Phalanx With Associated Nailbed Laceration. Reyes BA, Ho CA. J Pediatr Orthop Jun;37(4):

17 Repair

18 Need for more coverage local Flaps V-Y Flap

19 Reconstruction/Flaps

20 Cross finger flap Sanjay K. Sharma, M.D., F.A.C.S.

21 Distant Reconstruction

22 Then there s this Fingertip injuries after all

23 Make due with what you re given

24 Secondary Intention Changing paradigm of treatment Can allow slow closure over bone, tendon Moist environment Works great in children Motivated patients 3-8 weeks

25 Secondary Intention

26 Time Lapse video

27 Pediatric Fingertips Most common hand injury in child Amputations vs soft tissue crush injuries Supportive care: dressing changes and splints if distal phalynx fracture Ultimately good result

$distal phalanx fracture Proximal nail$

28 Trauma--Fingertips Seymour Fracture Displaced physeal or juxtaphyseal distal phalanx fracture Proximal nail avulsion with nailbed laceration Open fracture

29 Unusual variation of fingertip injuries Mallet Finger Axial injury hyperflexion Boutonniere Deformity Dislocations Lacerations Axial injury

30 Jersey Finger Technically Fingertip injury Hyperextension injury Avulsion of FDP tendon Bruising at volar distal phalanx Inability to bend (flex) DIP FDP Tendon

31 Summary Fingertip Injuries major healthcare burden Patient ED Provider Workplace/Employer Physician Take away points: Repair accurately Restore sensate tip with flaps Realize most if not all Fingertip injuries will heal spontaneously Consult your hand surgeon as needed for guidance

32 Thank You

Fractures of the Hand in Children Which are simple? And Which have pitfalls??

Fractures of the Hand in Children Which are simple? And Which have pitfalls?? Kaye E Wilkins DVM, MD Professor of Orthopedics and Pediatrics Departments of Orthopedics and Pediatrics University of Texas