Perionychium - Nail complex

Skin - glabrous thick epidermis with deep papillary ridges that create finger​prints

Innervation - sensory fibres from C6-8

Mechanism of injury crucial to determine injury pattern​

Measure defect size and determine 

Note presence of exposed bone

AP and lateral films

Treatment is patient- and digit-specific:

• Durable coverage​

• Preserve length and sensation

• Minimise pain (including neuroma) and donor site morbidity

• Maintain joint function

• Aesthetically acceptable result

Terminalisation

Split skin graft

Homodigital flaps

• Moberg flap (thumb only)

• V-Y advancement (Furlow) flap

• Bilateral triangular V-Y advancement (Kutler) flap​s

• Oblique triangular neurovascular island flap

• Hueston flap

• Souquet flap

• Step-advancement flap

• Reverse digital artery flaps

• Homodigital reverse vascular island flap 

Heterodigital flaps​

• Violates normal digit, sensibility not as good as with homodigital flaps​

• Cross finger flap

• Heterodigital neurovascular pedicled flap

• First dorsal metacarpal artery (Foucher) flap

• First dorsal metacarpal artery perforator (Quaba) flap

Regional flaps​

• Thenar flap​

Composite grafting​

• Non-microsurgical replantation of amputated fingertip​

• Children younger than 6 years

• Discouraged in severe crush injuries

Soft tissue loss without exposed bone

• Healing by secondary intention for small injuries​

• Skin grafting - increased incidence of cold intolerance, tenderness

Soft tissue loss with exposed bone​

• Bone shortening​

• Local flaps

Standard wound care

Splinting if required to avoid excessive postural positioning

Sensory re-education to begin as soon as patient able to perceive any type of sensory stimulus

Stages

• Desensitisation​

• Early phase discrimination and localisation

• Late phase discrimination and tactic gnosis