Soft-tissue injuries of the fingertip: methods of evaluation and treatment. An algorithmic approach

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the anatomy of the fingertip. 2. Describe the methods of evaluating fingertip injuries. 3. Discuss reconstructive options for various tip injuries. SUMMARY: The fingertip is the most commonly injured part of the hand, and therefore fingertip injuries are among the most frequent injuries that plastic surgeons are asked to treat. Although microsurgical techniques have enabled replantation of even very distal tip amputations, it is relatively uncommon that a distal tip injury will be appropriate for replantation. In the event that replantation is not pursued, options for distal tip soft-tissue reconstruction must be considered. This review presents a straightforward method for evaluating fingertip injuries and provides an algorithm for fingertip reconstruction.     

Reconstruction of short lower leg stumps with the osteomusculocutaneous latissimus dorsi-rib flap

To avoid a more proximal amputation at the distal part of the thigh, and when the knee joint is preserved, it is possible to lengthen short lower leg stumps. The authors report five cases in which the latissimus dorsi-rib flap was used to achieve a satisfactory functional prosthetic result. The bone segment is long enough to both lengthen the stump and allow its extremities to be firmly fixed to the tibia. Depending on the remaining tibia length, one or two ribs were included in the flap. The procedure allowed achievement of a 5-cm to 9-cm lengthening of the tibia. Bone healing time was 5 to 6 months and allowed prosthetic rehabilitation and ambulating 5 to 7 months after surgery. Final range of motion of the knee joint is compatible with normal ambulating, and the prosthesis is well tolerated. This procedure, which provides a large amount of skin, muscle, and bone, is very effective for reconstruction of short lower leg stumps.     

Successful replantation in the face of absent venous drainage: an experimental study

Inadequate venous outflow is the factor most responsible in digital replantation failure and is a common cause of tissue loss in general. An experimental replantation model utilizing the rabbit ear was used to study the extreme example of venous congestion: absent venous drainage in the replanted part. Results of this study support the use of single arterial inflow along with an efferent AV fistula for outflow in the management of replants with absent venous drainage. Potential indications for the use of an efferent arteriovenous fistula in digital revascularization include the following: (1) the finding of distal veins too small to reanastomose, as is often the case in children and at distal levels in adults; (2) preferential destruction of distal venous structures, as commonly seen in degloving or other dorsal injuries; and (3) in the management of postreplant venous thrombosis.     

Crossover replantation and fillet flap coverage of the stump after ectopic implantation: a case of bilateral leg amputation

A successful case of crossover replantation of the left foot to the stump of the right leg and temporary ectopic implantation of the right amputated foot on the forearm is described. The ectopically implanted right foot was used as a free fillet flap for the late reconstruction of the left leg stump. At the latest follow-up examination, 18 months after the accident, the patient was able to walk independently with a prosthesis on the stump of the left leg. Both the cross-replanted foot and the free filleted foot flap, used for the reconstruction of the left leg stump, have maintained adequate protective sensation. The importance of utilization of amputated parts for functional reconstruction is stressed. Crossover replantations and ectopic implantations should be considered in bilateral amputations for the salvage of at least one extremity.     

Fingertip replantation using the subdermal pocket procedure

Restoration of finger length and function are the goals of replantation after fingertip amputation. Methods include microsurgical replantation and nonmicrosurgical replantation, such as composite graft techniques. To increase the survival rates for composite grafts, the subcutaneous pocket procedure has been used as a salvage procedure. The subdermal pocket procedure, which is a modification of the subcutaneous pocket procedure, was used for replantation of 17 fingertips in 16 consecutive patients. Eight fingertips experienced guillotine injuries and the other nine fingertips experienced crush injuries. Revascularization of one digital artery without available venous outflow was performed for six fingers, and composite graft techniques were used for the other 11 fingers. The success rate was 16 of 17 cases. The difference in success rates for guillotine versus crush injuries was statistically significant. Comparison of patients with arterial anastomoses and patients without arterial anastomoses also indicated a statistically significant difference. Thirteen fingertips survived completely. One finger, demonstrating complete loss and early termination of the pocketing procedure, was amputated on the eighth postoperative day. Two fingers were partially lost because of severe crushing injuries. One finger demonstrated partial loss of more than one quarter of the fingertip, which required secondary revision, because the patient was a heavy smoker. The pocketing period was 8 +/- 1 days (mean +/- SD, n = 6) for the fingers revascularized with one digital arterial anastomosis and 13.3 +/- 1.9 days (n = 10) for the fingers successfully replanted with composite graft techniques. The mean active range of motion of the interphalangeal joint of the three thumbs was 65 +/- 5 degrees, and that of the distal interphalangeal joint of the other 11 fingers was 51 +/- 11 degrees. The static two-point discrimination result was 6.4 +/- 1.0 mm (n = 14) after an average of 11 +/- 5 months of follow-up monitoring. Compared with other methods, the subdermal pocket procedure has the advantages of exact subdermal/subdermal contact, a shorter pocketing period, and more feasible observation. The method can offer an alternative salvage procedure for fingertip amputations with no suitable vessels available for microsurgical replantation.     

Management of open tibial fractures

A prospective study was undertaken to accurately classify open tibial fractures and to evaluate the benefit of muscle flaps in the management of these injuries. From 191 open tibial fractures, 59 type III and 14 type IV open fractures were identified and managed prospectively. Fractures managed with open-wound techniques have a much higher complication rate than those closed with flaps. Results with flap coverage are affected by the biologic phase of the wound. The best results are seen in the acute flap coverage group and are thought to be secondary to removal of devitalized tissue with provision of a vascularized soft-tissue envelope prior to wound colonization. Flap coverage of the colonized subacute wound is subject to invasive infection with additional tissue loss. The subacute wound should be managed with open-wound technique until the parameters of a chronic localized wound are established, at which time flap coverage is again indicated. Microvascular free flaps are the preferred cover for type IV wounds because the local tissues are too ischemic and devitalized for transfer. With meticulous wound care and adherence to the enumerated surgical procedures, limb salvage may be achieved in most injuries.     

Minimizing impairment in laborers with finger losses distal to the proximal interphalangeal joint by second toe transfer

Traditionally, toe-to-hand transfers have been reserved for thumb amputations or for use after severe mutilating injuries. The authors report their experience with the use of second toe-for-finger amputations with preserved or reconstructible proximal interphalangeal joints in manual workers. The aim of the procedure was to reduce impairment and to upgrade the hand from a functional and cosmetic standpoint. Fifteen second-toe wrap-around or variations were carried out on 11 adults (18 to 41 years old). Four patients with two or more finger amputations received two sequential second toes; four patients with two finger amputations received one toe; and each of three patients with single-digit amputation received a single toe. All but one amputation were performed less than 3 weeks after the accident. All toes survived. Range of motion at the native proximal interphalangeal joint was more than 90 percent in all patients but one; however, it was minimal at the transplanted joints. Patient satisfaction was high from a cosmetic and functional standpoint. Ten of 11 laborers resumed their previous activity. On the basis of this experience, a classification with aesthetic and functional implications is proposed to help in the decision-making process when dealing with multidigital injuries. It is concluded that second-toe transfer is an excellent choice for finger amputation distal to the proximal interphalangeal joint in laborers. Its prime indication is for amputations of two fingers where at least one toe should be transferred, as required, to achieve an "acceptable hand" (three-fingered hand). Early transfer allows salvage of critical structures from the damaged finger, such as joints, tendons, and bone, that otherwise would be lost. Early transplantation is highly recommended.     

Adjacent and spontaneous neurotization after distal digital replantation in children

In an exclusively pediatric population, this retrospective study examined the functional and aesthetic results after distal replantation without nerve suture. The aim was to demonstrate, in the child, the presence of spontaneous nervous regeneration resulting in a fingertip pulp with discriminatory sensation. Eight amputations in eight children with a mean age of 9 years and 2 months on the day of the accident were reviewed. The cases were managed by a single surgeon over a period of 8 years and were collected from two different hand centers. The patients were then examined by a different surgeon, and the data were collected. Sensibility was evaluated using the Weber, Semmes-Weinstein, and wrinkle tests. The results were excellent, with mean values of 4.6 mm for the Weber test, 3.3 for the Semmes-Weinstein test, and a positive wrinkle test in all subjects. All patients thus recovered discriminatory sensation with minimal aesthetic sequelae. The usual factors adversely affecting the results of the replantation (ischemic time, level and mechanism of the amputation, and quality of the venous return) were examined, but no statistical analysis was performed because of the small sample size. This study demonstrates the presence of the clinical phenomenon of adjacent neurotization in the absence of nerve repair. It thus confirms that children are excellent candidates for replantation of the distal extremities, even when nerve suture is not performed.     

Retinoic Acid can Induce a Secondary Axis in Developing Buds of a Colonial Ascidian, Polyandrocarpa misakiensis

We have examined the effect of retinoic acid (RA) on axial pattern formation during bud development of the ascidian, Polyandrocarpa misakiensis . A bead containing various concentrations of RA was implanted into the distal portion of a bud at a site where morphogenic events do not normally occur. Control buds were implanted with beads containing dimethyl sulfoxide (DMSO), the solvent of RA. No apparent effect was observed in these buds containing beads treated with DMSO. In contrast, beads containing 100 μg/ml of RA could induce ectopic structures in the distal portion of buds in about 30% of the cases. The resulting animals had completely duplicated antero-posterior axes. Histological studies showed that, within two days of RA treatment, atrial epithelial cells situated just beneath the implanted bead became thickened and formed a gut rudiment that resembled the posterior structure of the animal. The effect of RA treatment was dose-dependent. The minimum concentration of RA required to induce a secondary axis was 100 ng/ml. Beads containing 1 mg/ml of RA had a lethal effect on the cells that surrounded the beads. These results are discussed in relation to the role of RA in axis formation and the mechanism by which positional values are specified during normal and aberrant bud development in ascidians.     

Functional analysis of limb recovery following autograft treatment of volumetric muscle loss in the quadriceps femoris

Severe injuries to the extremities often result in muscle trauma and, in some cases, significant volumetric muscle loss (VML). These injuries continue to be challenging to treat, with few available clinical options, a high rate of complications, and often persistent loss of limb function. To facilitate the testing of regenerative strategies for skeletal muscle, we developed a novel quadriceps VML model in the rat, specifically addressing functional recovery of the limb. Our outcome measures included muscle contractility measurements to assess muscle function and gait analysis for evaluation of overall limb function. We also investigated treatment with muscle autografts, whole or minced, to promote regeneration of the defect area. Our defect model resulted in a loss of muscle function, with injured legs generating less than 55% of muscle strength from the contralateral uninjured control legs, even at 4 weeks post-injury. The autograft treatments did not result in significant recovery of muscle function. Measures of static and dynamic gait were significantly decreased in the untreated, empty defect group, indicating a decrease in limb function. Histological sections of the affected muscles showed extensive fibrosis, suggesting that this scarring of the muscle may be in part the cause of the loss of muscle function in this VML model. Taken together, these data are consistent with clinical findings of reduced muscle function in large VML injuries. This new model with quantitative functional outcome measures offers a platform on which to evaluate treatment strategies designed to regenerate muscle tissue volume and restore limb function.     

A study on the prevalence of upper extremity repetitive strain injuries among the handloom weavers of West Bengal

Handloom is one of the oldest cottage industries in India, particularly in West Bengal, where a considerable number of rural people are engaged in weaving. Purposes of the present investigation were to clarify the prevalence of repetitive strain injuries in upper extremities among the handloom weavers and to identify the risk factors leading to its development. Fifty male handloom weavers were randomly selected from the population. A questionnaire (Kourinka et al., 1987) method including Borg scale assessment of pain, checklist analyses of the work, and time-motion studies for analyzing the repetitiveness/non-repetitiveness of the job were implemented. The time-motion analyses demonstrated that weaving occupied over 50% of the work cycle time for majority of subjects, and thus could be regarded as a repetitive activity. Statistical analyses revealed a highly significant correlation between the intensity of pain feeling and the repetitiveness on one hand, and the year of experience as a weaver on the other. By contrast, no significant relationship was observed between chronological ages of weavers and the pain intensity. These results suggested that highly repetitive works engaged for a long time could increase the intensity of the pain felt and would lead to repetitive strain injuries.     

Microsurgical replantation of the amputated nose

A case of successful replantation of the nose is presented. Two arteries and one vein were anastomosed, providing a stable framework for direct revascularization of the amputated nasal segment. This resulted in complete survival of the nose, with an excellent aesthetic result. However, despite successful microsurgical arterial and venous repair, significant postoperative blood loss still occurred as a result of anticoagulation. In cases of the amputation of specialized structures, the improved functional and cosmetic result obtained with replantation must be weighed against the risk of blood-borne disease transmission when postoperative transfusion is required. Recognizing the potential need for postoperative transfusion in these cases is important in allowing the surgeon to exercise appropriate judgment in deciding whether replantation should be performed.     

Replantation of an avulsive amputation of a foot after recovering the foot from the sea

A foot avulsion case, with the dismembered body part submerged in sea water for 1 hour, is presented. This report is unique in that it is the first to document the reattachment of a body part that had been submerged in sea water. It was not known how salt-water exposure would affect wound management. Differences in osmolarity and bacterial flora between the sea water and foot tissues have not caused any problems, and the patient has not suffered any vascular or infectious complications after replantation. Neurotization of the plantar surface by the tibial nerve, which was stripped off during amputation and replaced in its original traces, was the most critical part of convalescence. After management of such an interesting case, we conclude that exposure to sea water of the dismembered part should not be a contraindication for replantation surgery.     

Secondary expansion of a replanted scalp salvaged by an intrinsic arteriovenous shunt.

1. Although scalping injuries reported in most large series rarely involve young children, partial scalp replantation, even in a 2-year-old boy after a dog-bite avulsion, should also be warranted. However, technical difficulties because of the diminutive vasculature can be expected. 2. Unconventional methods for reestablishing inflow or outflow for the replanted scalp may become the only practical alternative and must not be overlooked. In this case, an arteriovenous shunt between the frontal branch of the superficial temporal artery within the amputated part itself to a more distal scalp vein at the superior edge of the fragment allowed high-output flow to maintain patency after recurrent thromboses of the conventional superficial temporal arterial anastomosis. This fistula was assumed to be the major contributor to nutrient flow of the remaining scalp, as the parietal branch was truncated along the margin of the avulsion. 3. Delayed tissue expansion is also an option. In this case, delayed expansion of the replanted scalp that survived allowed elimination of the skin grafts needed to cover areas where necrosis ensued, restoration of the anterior hairline, and resulted in a more normal appearance.     

Direct transplantation of uncultured hair‐follicle pluripotent stem (hfPS) cells promotes the recovery of peripheral nerve injury

We previously showed that the stem cell marker nestin is expressed in hair follicle stem cells which suggested their pluripotency. We subsequently showed that the nestin‐expressing hair‐follicle pluripotent stem (hfPS) cells can differentiate in culture to neurons, glial cells, keratinocytes, and other cell types and can promote regeneration of peripheral nerve and spinal cord injuries upon injection to the injured nerve or spinal cord. The location of the hfPS cells has been termed the hfPS cell area (hfPSCA). Previously, hfPS cells were cultured for 1–2 months before transplantation to the injured nerve or spinal cord which would not be optimal for clinical application of these cells for nerve or spinal cord repair, since the patient should be treated soon after injury. In the present study, we addressed this issue by directly using the upper part of the hair follicle containing the hfPSCA, without culture, for injection into the severed sciatic nerve in mice. After injection of hfPSCA, the implanted hfPS cells grew and promoted joining of the severed nerve. The transplanted hfPS cells differentiated mostly to glial cells forming myelin sheaths, which promoted axonal growth and functional recovery of the severed nerve. These results suggest that the direct transplantation of the uncultured upper part of the hair follicle containing the hfPSA is an important method to promote the recovery of peripheral nerve injuries and has significant clinical potential. J. Cell. Biochem. 110: 272–277, 2010. © 2010 Wiley‐Liss, Inc.     

Frequent meiotic recombination between the ends of truncated chromosome fragments of Saccharomyces cerevisiae

A single truncated chromosome fragment (TCF) in diploid cells undergoes frequent ectopic recombination during meiosis between markers located near the ends of the fragment. Tetrads produced by diploids with a single TCF show frequent loss of one of the two markers. This marker loss could result either from recombination of the TCF with one of the two copies of the chromosome from which it was derived or from ectopic recombination between the ends of the TCF. The former would result in shortening of a normal chromosome and lethality in one of the four spores. The high frequency of marker loss in tetrads with four viable spores supports recombination between the TCF ends as the main source of marker loss. Most of the spore colonies that display TCF marker loss contained a TCF with the same marker on both ends. Deletion of most of the pBR322 sequences distal to the marker at one of the subtelomeric regions of the TCF did not reduce the overall frequency of recombination between the ends, but affected the loss of one marker significantly more than the other. We suggest that the mechanism by which the duplication of one end marker and loss of the other occurs is based on association and recombination between the ends of the TCF.     

The intercostal to phrenic nerve transfer: an effective means of reanimating the diaphragm in patients with high cervical spine injury

Nerve transfers have been well described for the treatment of congenital and traumatic injuries in the brachial plexus and extremities. This series is the first to describe nerve transfers to reanimate the diaphragm in patients confined to long-term positive pressure ventilation because of high cervical spine injury. Patients who have sustained injury to the spinal cord at the C3 to C5 level suffer axonal loss in the phrenic nerve. They can neither propagate a nerve stimulus nor respond to implanted diaphragmatic pacing devices (electrophrenic respiration). Ten nerve transfers were performed in six patients who met these conditions. The procedures used end-to-end anastomoses from the fourth intercostal to the phrenic nerve approximately 5 cm above the diaphragm. A phrenic nerve pacemaker was implanted as part of the procedure and was placed distal to the anastomosis. Each week, the pacemaker was activated to test for diaphragmatic response. Once diaphragm movement was documented, diaphragmatic pacing was instituted. Eight of the 10 transfers have had more than 3 months to allow for axonal regeneration. Of these, all eight achieved successful diaphragmatic pacing (100 percent). The average interval from surgery to diaphragm response to electrical stimulation was 9 months. All patients were able to tolerate diaphragmatic pacing as an alternative to positive pressure ventilation, as judged by end tidal CO2 values, tidal volumes, and patient comfort. Intercostal to phrenic nerve transfer with diaphragmatic pacing is a viable means of liberating patients with high cervical spine injury from long-term mechanical ventilation.     

The use of arteriovenous anastomosis for replantation of the distal phalanx of the fingers.

Microvascular replantation at the distal phalangeal level has recently been reported by several authors, but as yet the rate of success has not been constant owing to the technical difficulties associated with small vessels. To solve this problem, over the last 4 years we have used arteriovenous anastomosis to reestablish either the arterial system or the venous drainage system in the 33 digits of our 23 patients. The results have been excellent, with a 91 percent success rate. Such results for replantation of the distal phalanx may be maintained and improved if a small venous graft with several branches is also utilized.