The effect of injury area on the success of treatment in digital nerve injury.

INTRODUCTION: The main objective of the current study is to investigate variations in postoperative outcomes that follow digital nerve repair in Zone 1 and Zone 2, respectively. We hope that by carrying out this investigation, we will be able to identify which zone has better sensation recovery and patient-reported outcomes, allowing us to identify the best way of conducting surgery for specific types of injuries. MATERIALS AND METHODS: A retrospective cohort study was conducted in patients with digital nerve injuries treated in a designated hand surgery clinic between January 2021 and December 2023. The study was guided by ethical consideration, where all participants gave their informed consent. Surgical interventions involved primary repair, autograft/allograft nerve grafting, nonsurgical approaches, as well as conduit repair in which results were determined using objective measures and patient feedback. RESULTS: Direct repair emerged superior among injuries of Zone 1 and Zone 2 with high success rates and good patient-reported outcomes. In general, injuries in Zone 1 had better sensory recovery than injuries in Zone 2 and this was associated with higher levels of satisfaction. Comparisons using statistical methods confirmed that direct repair outperformed other modalities. CONCLUSION: More importantly, the comparison of this study shows that repairs in Zone 1 are more successful than those in Zone 2 revealing direct repair as a superior method for digital nerve injuries. The difference is crucial because it suggests that surgical efficiency may depend on where the injury is. This means that direct repair should be given priority over the two zones, although surgeons will need to watch out for challenges related to Zone 2 injuries and adjust their strategies accordingly to obtain the best patient outcomes possible.

Monodigital Double Cross-Finger Flaps-A Novel Approach for Coverage of Large Volar Defects.

INTRODUCTION: A single cross-finger flap can only address digital defects of a limited size, and larger defects often require distant flaps such as abdominal or groin flaps that are cumbersome to perform and sometimes bulky. Two cross-finger flaps harvested from the same donor digit could offer a simple and effective solution for many such defects. In this study, we describe the technique of monodigital double cross-finger flaps and its clinical applicability, with evaluation of donor and recipient site morbidity. METHODS AND MATERIALS: A total of 10 subjects with large volar defects were included in the study. The demographic data, etiology, defect size, flap donor, and recipient sites were tabulated prior to surgery. Each subject was assessed for postoperative complications at the donor and recipient site and followed up for 6-12 months to document any flap or donor site morbidities. RESULTS: The subjects included 9 males and 1 female subjects, with an average age of 35.6 years (21-67 years). Most patients had posttraumatic defects, with 3 cases of full thickness burns and one with postsurgical tissue necrosis. All defects were volar, with 4 on the little finger, 3, 2, and 1 in the ring, index and middle fingers, respectively. No major postoperative complications were noted in any case. All flaps survived well with good contour, and donor fingers achieved near-normal range of flexion with only minimal restriction (10-15°) at the distal interphalangeal joint that did not result in any overall functional disability. CONCLUSIONS: Monodigital double cross-finger flap technique offers a simple and effective solution for reconstruction of large digital defects that are not amenable for closure by a classical cross-finger flap, and is a good alternative for other procedures, providing supple soft tissue coverage and no significant morbidity at the donor digit provided that there is preservation of a small skin bridge across the proximal interphalangeal joint.

Repair of distal finger soft-tissue defects with free fibular great toe neurovascular flaps.

BACKGROUND: This work aimed to investigate the change in fingerprint depth and the recovery rule of fingerprint biological recognition function after repairing finger abdominal defects and rebuilding fingerprint with a free flap. METHOD: From April 2018 to March 2023, we collected a total of 43 cases of repairing finger pulp defects using the free flap of the fibular side of the great toe with the digital nerve. After surgery, irregular follow-up visits were conducted to observe fingerprint clarity, perform the ninhydrin test or detect visible sweating with the naked eye. We recorded fingerprint clarity, nail shape, two-point discrimination, cold perception, warm perception and fingerprint recognition using smartphones. The reconstruction process of the repaired finger was recorded to understand the changes in various observation indicators and their relationship with the depth of the fingerprint. The correlation between fingerprint depth and neural repair was determined, and the process of fingerprint biological recognition function repair was elucidated. RESULT: All flaps survived, and we observed various manifestations in different stages of nerve recovery. The reconstructed fingerprint had a clear fuzzy process, and the depth changes of the fingerprint were consistent with the changes in the biological recognition function curve. CONCLUSION: The free flap with the digital nerve is used to repair finger pulp defects. The reconstructed fingerprint has a biological recognition function, and the depth of the fingerprint is correlated with the process of nerve repair. The fingerprint morphology has a dynamic recovery process, and it can reach a stable state after 6-8 months.

Bone grafting combined with a spiral flap technique for the reconstruction of fingertip amputations.

BACKGROUND: Various reconstructive options exist for distal finger and pulp defects, including grafting and local or distant flaps. In addition to reconstructing the normal anatomical structure, preserving the sensory function of the finger is crucial. This study presents the results of using bone grafting combined with a spiral flap (BGcSF) technique for reconstructing pulp defects accompanied by bone loss. METHODS: Twenty-three patients with fingertip defects were treated using the BGcSF technique. Flap sensitivity was assessed us-ing the Semmes-Weinstein monofilament (SWM) and static two-point discrimination (2PD) tests at six months postoperatively. Cold intolerance of the affected fingers was evaluated using the Cold Intolerance Severity Score (CISS) questionnaire at one year postop-eratively. Patient satisfaction was assessed using the Michigan Hand Outcomes Questionnaire (MHQ). Range of motion (ROM) for the proximal and distal interphalangeal joints was measured with a goniometer at one year postoperatively. RESULTS: Distal flap necrosis, affecting 10-15% of the flap area, was observed in one patient. No other complications were noted. The mean static two-point discrimination value at six months postoperatively was 5.6 mm, and the mean SWM score was 3.56. The mean CISS score at one year postoperatively was 18.8. The mean active ROM angle for the proximal interphalangeal joint was 106.7 degrees, and for the distal interphalangeal joint, it was 65.4 degrees. The mean MHQ score at one year postoperatively was 18.5. CONCLUSION: The BGcSF technique provides soft tissue with a texture similar to that of the fingertips and supports effective sensory repair. It can be considered a viable option for fingertip reconstruction in cases where replantation is not feasible.

Digital Thermal Necrosis Resulting in Amputation After Removing a Tungsten Carbide Ring With a High-Speed Metal Burr: A Case Report.

CASE: A 41-year-old man removed a tungsten carbide ring from his left index finger by cutting it off with a high-speed metal burr. The patient presented two days later with a pink and perfused left index finger with circumferential dry gangrene along the area of the ring, active flexor and extensor tendon excursion, and decreased sensation distally. Within 24 hours, the wound developed into wet gangrene and diffuse cyanosis requiring amputation. CONCLUSION: After reviewing previously documented methods to remove tungsten carbide rings, the authors conclude clinicians should be cognizant of the potential complications associated with the use of a high-speed metal burr.

Nail bed trauma reconstruction and artificial nail replacement - a case report.

Nail bed reconstruction is crucial after fingertip trauma, impacting both function and aesthetics. In this article, the authors describe a case of partial distal phalanx amputation of the index finger with laceration of the nail bed's remaining part. A traumatically elevated skin-fat flap covered the exposed bone on the fingertip, preserving finger length and sensitivity on the radial side. A full-thickness skin graft from the forearm closed a secondary defect on the finger pulp. Nail bed suturing prevented scarring and nail deformity, and a temporary artificial plastic nail replacement maintained the nail bed's shape. Temporary artificial nail replacements protect the regenerating fingertip bed, promote healing, and prevent nail deformities. Proper adaptation of lacerated nail bed edges, supported by either the patient's own nail or a temporary artificial nail, is crucial for optimal fingertip restoration, including proper nail shape.

Extensor tendon rupture and preoperative mri confirmations of suture anchor prolapse: a case report and literature review.

BACKGROUND: While suture anchors are widely used in medical procedures for their advantages, they can sometimes lead to complications, including anchor prolapse. This article presents a unique case of suture anchor prolapse at the base of the distal phalanx of the little finger after extensor tendon rupture reconstruction surgery. CASE PRESENTATION: A 35-year-old male, underwent extensor tendon rupture reconstruction using a non-absorbable suture anchor. After seven years the patient visited our outpatients complaining of stiffness, pain, and protrusion at the surgical site. Initial X-ray imaging suggested suggesting either a fracture of the distal phalanx or tendon adhesion but lacked a definitive diagnosis. Subsequent magnetic resonance imaging (MRI) revealed bone connectivity between the middle and distal phalanges with irregular signal shadow and unclear boundaries while maintaining a regular finger shape. MRI proved superior in diagnosing prolapsed suture anchors, marking the first reported case of its kind. Surgical intervention confirmed MRI findings. CONCLUSIONS: Suture anchor complications, such as prolapse, are a concern in medical practice. This case underscores the significance of MRI for accurate diagnosis and the importance of tailored surgical management in addressing this uncommon complication.

Amputated Digit Replantations: Critical Digit Ischemia Timing, Temperature, and Other Predictors of Survival.

INTRODUCTION: A common consideration for replantation success is the ischemia time following injury and the preservation temperature. A classic principle within the hand surgery community describes 12 hours of warm ischemia and 24 hours of cold ischemia as the upper limits for digit replantation; however, these limits are largely anecdotal and based on older studies. We aimed to compare survival data from the large body of literature to aid surgeons and all those involved in the replantation process in hopes of optimizing success rates. METHODS: The PubMed database was queried on April 4th, 2023, for articles that included data on digit replantation survival in terms of temperature of preservation and ischemia time. All primary outcomes were analyzed with the Mantel-Haenszel method within a random effects model. Secondary outcomes were pooled and analyzed using the chi-square statistic. Statistical analysis and forest plot generation were completed with RevMan 5.4 software with odds ratios calculated within a 95% confidence interval. RESULTS: Our meta-analysis identified that digits preserved in cold ischemia for over 12 hours had significantly higher odds of replantation success than the amputated digits replanted with 0-12 hours of warm ischemia time ( P ≤ 0.05). The odds of survival in the early (0-6 hours) replantation group were around 40% greater than the later (6-12 hours) replantation group ( P ≤ 0.05). Secondary outcomes that were associated with higher survival rates included a clean-cut amputation, increased venous and arterial anastomosis, a repair that did not require a vein graft, and replants performed in nonsmokers ( P ≤ 0.05). DISCUSSION: Overall, these findings suggest that when predicting digit replantation success, time is of the essence when the digit has yet to be preserved in a cold environment. This benefit, however, is almost completely diminished when the amputated digit is appropriately maintained in a cold environment soon after injury. In conclusion, our results suggest that there is potential for broadening the ischemia time limits for digit replant survival outlined in the literature, particularly for digits that have been stored correctly in cold ischemia.

[Effectiveness of Kirschner wire fixation for proximal phalangeal bone avulsion fracture caused by A2 circular trochlea injury of flexor digitorum tendon].

Objective: To explore the mechanism, surgical method, and effectiveness of proximal phalangeal bone avulsion fracture caused by A2 circular trochlea injury of the flexor digitorum tendon. Methods: A retrospective analysis was conducted on the clinical data of 4 patients with proximal phalangeal bone avulsion fracture caused by A2 circular trochlea injury of flexor digitorum tendon admitted between May 2018 and September 2022. The patients were all male, the age ranged from 26 to 52 years, with an average of 33 years. The injured fingers included 1 case of middle finger and 3 cases of ring finger. The causes of injury were rock climbing of 2 cases and carrying heavy objects of 2 cases. Preoperative anteroposterior and lateral X-ray films and CT examination of the fingers showed a lateral avulsion fracture of the proximal phalanx, with a fracture block length of 15-22 mm and a width of 3-5 mm. The total active range of motion (TAM) of the injured finger before operation was (148.75±10.11)°. The grip strength of the middle and ring fingers was (15.50±2.88) kg, which was significantly lower than that of the healthy side (50.50±7.93) kg ( t=-8.280, P<0.001). The time from injury to operation was 2-7 days, with an average of 3.5 days. One Kirschner wire with a diameter of 1.0 mm was used for direct fixation through the fracture block, while two Kirschner wires with a diameter of 1.0 mm were used for compression fixation against the fracture block. The fracture healing was observed, and the TAM of the injured finger and the grip strength of the middle and ring fingers were measured. The finger function was evaluated according to the upper limb functional assessment trial standards of the Chinese Medical Association Hand Surgery Society. Results: The incisions all healed by first intention after operation. All patients were followed up 6-28 months, with an average of 19 months. X-ray films showed that all avulsion fractures of proximal phalanx reached bony union, and the healing time ranged from 4 to 8 weeks, with an average of 4.6 weeks. At last follow-up, the grip strength of the middle and ring fingers was (50.50±7.76) kg, which significantly improved when compared with preoperative one ( t=-8.440, P<0.001). The TAM of the injured finger reached (265.50±2.08)°, and there was a significant difference when compared with preoperative one ( t=-21.235, P<0.001). According to the upper limb functional assessment trial standards of the Chinese Medical Association Hand Surgery Society, the finger function was all evaluated as excellent in 4 cases. Conclusion: Using Kirschner wire fixation through bone blocks and external compression fixation of bone blocks for treating proximal phalangeal bone avulsion fracture caused by A2 circular trochlear injury of the flexor digitorum tendon can achieve good effectiveness.

Analyzing attempt and success factors for amputated digit replantation in Japan using the diagnosis procedure combination database.

The number of amputated finger replantation has declined in the USA and Germany in recent years; however, there have been no reports on recent trends in Japan. We examined the current practices, attempts, and success factors of digit replantation in Japan. We hypothesized that the rates of digit replantation and success rates were consistently standardized in Japan. The diagnosis procedure combination database was used to analyze 14004 cases from April 2014 to March 2020, excluding multiple-digit amputations, thus focusing on 13484 patients. We evaluated replantation success rates and identified factors influencing replantation decisions using multiple logistic regression analysis. The key findings included a higher frequency of replantation in thumb cases and surgeries during overtime hours, on Sundays, and in educational institutions. Success rates were notably higher for thumb replantations and patients under 20 years of age. Patients over 65 years of age treated with urokinase showed higher failure rates, unrelated to regional or hospital case volumes. The number of amputated digit replantation surgeries in Japan was high during overtime hours, on Sundays, and in educational institutions. Region, hospital type, and hospital case volume were not associated with a low success rate across Japan.

One-stage secondary debulking procedure: A unique technique to restore the differential contour of digit after groin flap reconstruction.

BACKGROUND: Pedicled groin flap is a reliable reconstructive method for digits. However, problems with the contour, mobility, and sensation, especially while providing strict thin skin coverage still exist. PATIENTS AND METHODS: A total of 17 cases with 36 digits injured by trauma were identified. One-stage secondary debulking procedure was adopted for flap revision. The skin over the flap was harvested as a full-thickness graft. At the dorsal side of the reconstructed digit, the subcutaneous tissue and fat were debulked till the deep fascial layer. At the volar side, the flap was debulked till the superficial fascial layer. The skin was then re-grafted. The outcomes were reviewed after 12 months follow-up. RESULTS: The average timing for debulking procedure after flap reconstruction was 116 days. After removal of bolster dressing 7 days after debulking, all the grafted skin took well. A mean length of 2.5 cm of digit was preserved for the non-replantable digits. The reconstructed digits achieved comparable diameter and contour with that of the contralateral side. The two-point discrimination of the injured digits of adults was 10.4 ± 1.6 mm. Using a 5-point Likert scale, post-debulking digits showed statistically significant improvement compared to pre-debulking digits. The evaluation of the patients' satisfactory outcomes of the reconstructed digits was judged as "very satisfying" in 12 patients (75 %) and "good" in 4 patients (25 %). CONCLUSIONS: One-stage secondary debulking procedure resulted in excellent functional and esthetic outcomes for digits according to different structures of the dorsal and volar sides. LEVEL OF EVIDENCE: IV, Retrospective.

Anatomy, evolution, and clinical aspects of the superextended-intercompartmental-supraretinacular artery perforator flap (SISAP-flap): A proof of concept.

BACKGROUND: Extended soft tissue defects of the fingers-irrespective of their origin-are challenging to treat. In cases of missing amputates or crush injuries, the options are often limited to further amputation, ray resection, or free tissue transplantation. The SISAP-flap was developed to add an extra option to treat finger avulsion injuries or otherwise extended soft tissue finger defects. METHODS: Cadaveric SISAP-flaps were individually dissected, tested for arterial perfusion using red ink and radiopaque dye, and transposed into artificially created same-size defects. After introducing this flap in the clinic, which was partially successful in the first patient, we modified the flap to its definite design. RESULTS: Average cadaver flap size ranges between 11 cm and 22 cm in length, allowing dorsal wrapping of the flap over the fingertip and way back to the palmar metacarpophalangeal-joint. The flap is based on the distal web space perforator, which is commonly used by a dorsal metacarpal artery flap and supercharged using an intercompartmental, supraretinacular artery. Donor sites were closed primarily with little tension. Application of the flap in the clinic resulted in satisfactory functional and esthetic outcomes. CONCLUSION: The SISAP-flap is a new option for the reconstruction of extended finger defects and should be added to the reconstructive surgeon's armamentarium of pedicled flaps, providing relatively short operating times and promising clinical outcomes.

[Two-Stage Reconstruction in Bony Finger Joint Defects - Long-Term Results]. / Zweizeitige Arthrodese bei knöchernen Fingergelenkdefekten ­ Langfristige Ergebnisse.

BACKGROUND: Bony defects in finger injuries and infections impose high demands on their treatment due to the close anatomic relationships. Ideally, the injuries are entirely treated in emergency care. Due to the mechanism of the accident, contaminated and compromised soft tissues are often present and set limits to single-stage treatment. We present the long-term subjective and functional results after two-stage reconstruction of bony finger joint defect injuries. PATIENTS AND METHODS: Over a period of 15 years, a total of 40 patients with 43 fingers were treated due to a defect injury in the phalanges. Initially, the finger was stabilised with Kirschner wires after debridement. After consolidation of the soft tissue, the bone was reconstructed in a subsequent operation by interposition of an iliac crest graft. Complications occurred in 9 patients. Twenty-five patients with 27 fingers were followed up for 10.3 years. Range of motion, length of the affected finger, and grip force, each in relation to the contralateral extremity, were recorded. In addition to a subjective assessment of the global result, the daily function was determined by means of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. RESULTS: Significant differences compared with the contralateral extremity (p<0.05) were found in length (70 mm; 91.0%) and total mobility of the affected finger (95°; 46.0%), hand span when the thumb was involved (202.5 mm; 93.4%), and power grip when one of the fingers was injured (30 kg; 84.1%). The DASH score was 4.2 points (0-55.8). Subjectively, 88% of patients were satisfied with the treatment outcome. CONCLUSION: In case of contaminated and compromised soft tissues, the two-stage treatment of bony defect injuries in finger joints by arthrodesis of the joint is a reliable treatment strategy. In the long run, it results in a very satisfactory function of the hand in everyday life although significant differences have been measured compared with the contralateral extremity.

Combined with the first dorsal (plantar) metatarsal artery pedicle free bilobed flap with a cell scaffold for the repair of a mid-distal adjacent finger defect: a retrospective study.

PURPOSE: Assessing the clinical effectiveness of combining with the first dorsal (plantar) metatarsal artery pedicle free bilobed flap with a cell scaffold to repair mid-distal defects in adjacent fingers. METHODS: From September 2012 to April 2022, 21 patients with 42 mid-distal defects of adjacent fingers underwent treatment using combined with the first dorsal (plantar) metatarsal artery pedicle free bilobed flap with a cell scaffold. The flaps size ranged from 2.1 cm * 1.6 to 4.9 cm * 3.2 cm. Follow-up evaluations included assessing function, sensation, and appearance, etc. of the injured fingers and donor areas. RESULTS: All 42 flaps survived in 21 patients without any vascular crises, and the wounds healed in phase I. The mean follow-up time was 12.2 months (range 7-22 months). During follow-up, in injured fingers, according to the Michigan Hand Outcomes Questionnaire (MHOQ), the functional recovery and appearance were satisfactory; in Dargan Function Evaluation (DFE), the results were both "excellent" in fourteen patients, "excellent" and "good" in five patients, both "good" in one patient, "good" and "general" in one. In static two-point discrimination (2PD), the variation ranges from 4 to 9 mm in injured fingers and 6-10 mm in donor toes. Cold Intolerance Severity Score (CISS) is mild in all patients. The visual analogue score (VAS) showed no pain in the injured fingers and donor toes. No deformities or other complications were noted at the donor toes. According to Chinese Manchester Foot Pain and Disability Index (C-MFPDI), there was no morbidity on foot function in all donor areas. CONCLUSION: The surgical procedure of combined with the first dorsal (plantar) metatarsal artery pedicle free bilobed flap with a cell scaffold for the repair of mid-distal adjacent fingers defect is highly satisfactory. This approach helps the injured fingers to achieve good function, sensibility and appearance, while also achieving satisfactory results in the donor toes.

Retrospective study of Ishiguro's technique for mallet bone finger in children: long-term follow-up and analysis of predictors in outcomes.

PURPOSE: There is no consensus on the optimal treatment of bony mallet finger in the paediatric population due to a lack of studies in children. The Ishiguro technique is simple and less invasive, and treatment with K-wire fixation seems to provide better results for extension lag in bony mallet finger according to the literature. A retrospective cross-sectional study with long-term follow-up was performed to evaluate the functional and clinical outcomes of this method in children. Preoperative and intraoperative predictors of outcome were investigated. METHODS: From June to December 2022, we evaluated 95 children who underwent extension K-wire block from 2002 to 2012. Eighty-four children were included (mean age 14.8 ± 1.68 years) for a mean long-term follow-up of 11.6 ± 2.3 (8-16) years. Clinical and radiographic features were assessed. Pain and functional outcomes were assessed using Crawford criteria, range of motion (ROM) at the distal interphalangeal joint (DIPJ), loss of extension, and VAS scale. Univariate and multivariate regressions were used to assess which variables might predict the worst outcomes at long-term follow-up. RESULTS: Bone union and pain relief were always achieved. There were no complaints of potential growth impairment or nail deformity. 82.1% of patients showed excellent and good results. Fifteen patients had fair results. CONCLUSIONS: Although there are currently no significant differences between surgery and orthosis in adults, the Ishiguro technique is more effective in children when it comes to outcomes in the treatment of mallet fingers. A high percentage of excellent and good results were achieved, and no epiphyseal damage or nail deformity was reported. A strong and significant correlation was found between the worst outcomes and either delayed treatment time or excessive flexion angle.

[Preliminary application of antibiotic bone cement directly inducing skin regeneration technology in repairing of wound in lateral toe flap donor area].

Objective: To investigate the feasibility and effectiveness of antibiotic bone cement directly inducing skin regeneration technology in the repairing of wound in the lateral toe flap donor area. Methods: Between June 2020 and February 2023, antibiotic bone cement directly inducing skin regeneration technology was used to repair lateral toe flap donor area in 10 patients with a total of 11 wounds, including 7 males and 3 females. The patients' age ranged from 21 to 63 years, with an average of 40.6 years. There were 3 cases of the distal segment of the thumb, 2 cases of the distal segment of the index finger, 1 case of the middle segment of the index and middle fingers, 1 case of the distal segment of the middle finger, and 3 cases of the distal segment of the ring finger. The size of the skin defect of the hand ranged from 2.4 cm×1.8 cm to 4.3 cm×3.4 cm. The disease duration ranged from 1 to 15 days, with an average of 6.9 days. The flap donor sites were located at fibular side of the great toe in 5 sites, tibial side of the second toe in 5 sites, and tibial side of the third toe in 1 site. The skin flap donor site wounds could not be directly sutured, with 2 cases having exposed tendons, all of which were covered with antibiotic bone cement. Results: All patients were followed up 6 months to 2 years, with an average of 14.7 months. All the 11 flaps survived and had good appearance. The wound healing time was 40-72 days, with an average of 51.7 days. There was no hypertrophic scar in the donor site, which was similar to the color of the surrounding normal skin; the appearance of the foot was good, and wearing shoes and walking of the donor foot were not affected. Conclusion: It is a feasible method to repair the wound in the lateral foot flap donor area with the antibiotic bone cement directly inducing skin regeneration technology. The wound heals spontaneously, the operation is simple, and there is no second donor site injury.

Syndactylized glabrous flaps for multiple finger palmar defects.

BACKGROUND: Palmar finger or pulp defects require coverage with glabrous tissue to achieve a good match with the lost tissue. The management of multiple finger palmar or pulp defects is challenging because these defects may not always be suitable for local or pedicled flaps. In such situations, syndactylizing free or pedicled flaps can be used. PATIENTS AND METHODS: We evaluated the results of free glabrous flaps syndactylizing across multiple finger defects. The two flaps used were the superficial branch of the radial artery (SUPBRA) flap and hypothenar free flap. Seven syndactylized glabrous free flaps were used to cover the defects in 16 fingers. The functional results and complaints were also assessed. RESULTS: Mean flap size was 14.35 cm2. Six flaps survived. Postoperative evaluation data were obtained for the 13 fingers. All the patients returned to their previous work. All patients had a diminished protective sensation of at least 4.31 according to the SWM test. The mean two-point discrimination score of the patients was 9.9 mm (7-14). One finger had a PIP joint flexion contracture of 30°, no donor-site complaints were observed. CONCLUSION: The advantages of these flaps include single operation site, strong glabrous tissue coverage, low risk of flexion contracture, and adequate tissue size for large defects. Disadvantages include two-stage and complex microsurgical operations, prolonged treatment, and hospital stay.

Microsurgical reconstruction of the nail.

Very often, post-traumatic defects involve multiple tissues. Microsurgical techniques can reconstruct them with tissues taken from a toe: from the nail complex alone to compound osteo-onychocutaneous flaps. Several techniques have been reported since the 1980s. This paper describes techniques and indications for microsurgical nail reconstruction. Technique differs according to the deficit, and first and foremost whether only the nail complex is involved or whether other components of the fingertip important for the normal growth of the nail, such as the phalanx bone or the finger pad, are also missing (toenail flaps and the custom-made osteo-onychocutaneous flaps). For most patients the absence of a fingernail is an esthetic rather than functional concern, and the outcomes of microsurgical reconstruction are far from ideal in this regard. We prefer to reserve reconstruction for symptomatic patients with functional impairment.

Proximal phalanx flexor tendon tenodesis after severe frostbite in a rock climber.

A 32 year-old climber sustained a grade IV frostbite injury to the right hand which required amputation at the neck of the proximal phalanges of all the long fingers. To increase range of motion and strength in the remaining metacarpophalangeal joints, tenodesis of the flexor digitalis superficialis and profundus tendons onto the proximal phalanges was performed. Several revisions for removal of bony spurs, dorsal skin advancement flaps and web space deepening were necessary. After 2 years, the patient achieved 10-0-100° metacarpophalangeal joint range of motion in extension-flexion and could do full body-weight pull-ups on 1 cm deep holds, lift 50 kg on a 2 cm deep hold (normal contralateral side, 40 kg), climb up to F7a routes and use a mechanical 4-finger functional prosthesis.

Fingertip injuries and their reconstruction, focusing on nails.

The fingertip is a complex anatomical structure that is frequently injured, especially in manual workers. Different classifications have been reported, considering injury orientation, level and geometry. To optimize treatment planning, the area of soft-tissue defect should be considered. Treatment aims to conserve as long a finger as possible, restore sensation (S3 + or more) and ensure a pleasant esthetic appearance. When amputation occurs, the best treatment is replantation when conditions allow. When this is not possible, the fingertip should be used as a composite graft or the nail complex can be grafted and soft tissue reconstructed, according to the preferred method. In defect without amputation or if the distal part of the finger is not present or not useful, many reconstructive techniques have been described. Depending on the injury, patient characteristics and requirements and the surgeon's skills and experience, the treatments vary from secondary healing to free flaps. In this paper, the various treatment options are described and discussed. Nowadays, considering most variables, the best treatment in fingertip injury is secondary healing with occlusive or non-occlusive dressing, even in case of bone exposure. This simple solution is able to restore a nearly normal fingertip with good sensation without further injuring the hand.