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Copyright 2015 by the American Society for Surgery of the Hand. All rights reserved.
Current Concepts
The management of thumb tip injuries has undergone great changes in recent years. The
traditional armamentarium of aps has been expanded and replaced by a wide variety of aps
with more versatility and less donor side morbidity. Parallel to the development of new aps, the
conservative treatment of thumb tip injuries with semi-occlusive dressing has gained ground in
the treatment of these injuries. Although tedious and time-consuming, and requiring intensive
communication with the patient to explain the look and occasionally fetid smell of the wound,
this technique yields excellent results with respect to restoring contour and sensibility in pulp
injuries. The article gives an update on the current options for treating thumb tip injuries
including the most commonly applied aps. (J Hand Surg Am. 2015;40(3):614e622. Copyright
2015 by the American Society for Surgery of the Hand. All rights reserved.)
Key words Thumb, tip injuries, treatment concepts.
From the Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg,
Germany.
Received for publication July 26, 2014; accepted in revised form September 28, 2014.
No benets in any form have been received or will be received related directly or indirectly
to the subject of this article.
614
2015 ASSH
Corresponding author: Gnter Germann, MD, PhD, University of Heidelberg Ethianum for
Clinic Plastic, Hand and Reconstructive Surgery, Vostr. 6, 69115 Heidelberg, Germany;
e-mail: guenter.germann@ethianum.de.
0363-5023/15/4003-0038$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2014.09.028
INJURIES
ARE
THE
Current Concepts
(cross-nger),16,17 distant island aps (homodigital),18e22 and heterodigital,23 metacarpal perforator,24 and microsurgical free.25e32
Among these numerous options, the reconstructive
surgeons duty is to choose the best method that
meets the patients needs. Because of the specic
anatomical characteristics and highly sophisticated
function of the ngertips, it has long been believed
that palmar defects of the ngertip should be reconstructed using palmar skin that has characteristics
similar to those of the ngertip. However, because
there is a possibility of postoperative scar contracture
at the ap donor site, other aps have also been
commonly used.
most frequently
encountered injuries in the upper limb, because
it is the main autologous tool used by primates
and humans. The ngertips are the most important
organs of tactile sensibility. Two-point discrimination
usually is below 5 mm owing to the density of
VaterePacini bodies and the branches of the palmar
digital nerves responding to tactile stimuli and
providing skin sensibility. The anatomic structures of
the pulp with its subcutaneous architecture are laid
out to withstand substantial pressure and shear force.
Rich arterial blood is supplied to the ngertip by
terminal branches of the main palmar digital arteries.
Venous blood drainage on the palmar side is provided
by the supercial palmar veins and oblique communicant veins.
Classication of thumb tip defects is not clearly
dened in the literature. Usually defects are dened
arbitrarily as small or large.1 Other denitions use the
structures involved such as the pulp, nail, and bone,
which also dene the location of the injury.2,3 Using
both criteria denitions most likely gives the best
basis for selecting the appropriate reconstructive
method.
The selected technique of defect reconstruction
depends on many factors such as the nature of the
injury; the size, location, and condition of the defect;
the patients age, gender, and general health condition; and the patients professional prole.
The goals in ngertip amputation reconstruction
are to cover the defect with a satisfactory cosmetic
appearance, establish maximum tactile gnosis, preserve the length of the thumb, obtain a well-padded
pulp tissue, preserve an intact nail bed, and minimize time off work.
Numerous methods for reconstructing ngertips
are described in the literature, which correlate to the
principle of the reconstructive ladder. These range
from healing by secondary intention and skin grafting
to simple palmar VeY plasty and bilateral VeY
plasty,4e6 various island aps, and even free toe pulp
transfer for large defects. Skin grafting of the defect is
an easy method but usually results in poor sensory
function; therefore, it should be considered only if
other options are not feasible. Healing by secondary
intention (eg, under a semi-occlusive dressing) has
been established as a good method for small to medium defects without exposure of bone or tendons. If
successful, it results in an excellent contour and
consistency of the pulp with satisfactory return of
sensory function.
Flaps used for thumb tip reconstruction are
classied as homodigital aps,4e15 heterodigital
INGERTIP
615
616
FIGURE 1: A Palmar defect of the tip of the thumb after debridement. B Dissection of the Moberg ap based on the proper neurovascular bundles. C The ap is advanced and sutured into the defect.
Current Concepts
Semi-occlusive dressing
Treatment of ngertip injuries with a semi-occlusive
dressing is simple and inexpensive.52e54 The wound
is covered with a transparent adhesive dressing after
cleaning and debridement (Figs. 6, 7). For protection
and to avoid slipping of the transparent adhesive dressing, an additional cover is added with a soft crepe
bandage. The patient is instructed to make full use of the
hand and the injured nger without immobilization.
The dressing is left in place for 1 week (at least 5 d) and
is then replaced on a weekly basis until the wound
completely heals. During dressing changes it is necessary to clean the skin close to the defect without
cleaning the wound itself before the new dressing is
applied. It is important not to change the dressing
frequently, to avoid contamination and reduce the
r
617
Current Concepts
FIGURE 2: A Hydrouoric acid burn of the tip of the thumb with loss of the nail bed and exposure of the proximal phalanx. B Start of
dissection of the rst DMCA ap. It is important to preserve the large subcutaneous veins to provide the best possible venous outow.
C The ap is raised and the vascular pedicle is secured by including the fascia of the interosseus muscle. D The ap after healing and
incorporation into the defect.
618
FIGURE 3: A Recurrent arteriovenous malformation involving the entire palmar tip of the thumb. B Resection defect after complete
removal of the vascular tumor. C Tip reconstruction with a neurovascular-sensible rst DMCA ap to restore sensibility and the soft
tissue defect simultaneously. D The ap at 2 weeks after surgery.
Current Concepts
DISCUSSION
Advances in anatomical knowledge, progress in surgical instruments and available devices, and innovative surgical techniques have enhanced soft tissue
reconstruction of the hand. Constant improvement in
design and harvesting techniques has led to ap renements resulting in considerably more appealing
aesthetic results in soft tissue reconstruction.
Although local ap coverage has the benet of
preserving the thumb length and is preferred for
wound closure after bone shortening, it is unfeasible
J Hand Surg Am.
619
Current Concepts
FIGURE 4: A Avulsion injury of the dorsal tip of the thumb with loss of the nail bed and exposed bone. B Design of the reversed radial
ow homodigital ap (Moschella ap). C The ap is raised based on the recurrent dorsal radial artery. D The ap is sutured into the
defect.
620
C
FIGURE 5: A An ulnar reversed-ow homodigital island ap (Brunelli ap) is raised on the dorsal ulnar recurrent artery. B A small dog
ear is left in this case to protect the vascular pedicle. C Another case in which the ap is used for tip reconstruction.
Current Concepts
621
FIGURE 7: A Clinical example of an oblique thumb tip amputation with a jagged blade. The nail bed is partially preserved. B Dorsal
aspect of the wound. C, D Clinical appearance at 1 and 2 weeks after treatment with semi-occlusive dressing. Slight maceration of
healthy skin is caused by the dressing material. E After approximatly 4 weeks, the thumb tip has an almost normal contour. Nail growth
has returned. The ngerprint pattern is not yet completely restored.
Current Concepts
REFERENCES
622
Current Concepts