Current Orthopaedics (2002) 16, 271^285

c 2002 Elsevier Science Ltd. All rights reserved.

doi:10.1054/cuor.2002.0278, available online at http://www.idealibrary.com on

MINI-SYMPOSIUM:THE TRAUMATISED HAND

(iv) Fingertip injuries: a review of indications and

methods of management
D. Sammut
The Chestereld Hospital, 3 Clifton Hill, Bristol BS8 1BP, UK

INTRODUCTION
The human hand is frequently in harms way, on the front
line of interaction with the environment in most work
activity and also in the leisure and domestic setting. The
ngertips, as a collective functional unit, bear the statistical brunt of such injuries. Reconstruction of the ngertips forms a signicant workload of the reconstructive
hand surgeon.
Pulp skin has specialised mechanical qualities. It is robust, yet deformable so as to enable stimulation of the
dense population of sensory end-organs it contains. In
the interpretation of outside stimuli, the humans main
receptive organs are eyes and ngertips. The hand and
ngertips, in contrast with the organs of sight, perform
an executive as well as a receptive role. Fingers with
insensate or painful pulp perform poorly and are often
excluded from activities that demand multi-digit coordination.
The cosmetic importance of the hand, and in particular the digits, is not to be underestimated. Irrespective of
custom and attire, in virtually all societies, the hand is
constantly on display and is as important a cosmetic unit
as the face. Its gestures may be as eloquent and as expressive. Function and appearance are closely interlinked. Fingers that move and perform naturally attract
little attention, despite signicant injury or surgical alteration. Smooth, healthy-looking skin cover, as well as
uid movement, form important aspects of social acceptability and condent behaviour. In addition, it is the
hand that forms the most frequent point of physical contact between strangers and acquaintances, the handshake a universal form of greeting.
It is important not to overrate the signicance of occupation in the management of ngertip injuries. While
some methods might entail an unacceptable time o
work for, say, the manual worker whose main concern is
strength and durability, all will require a measure of painfree dexterity. Irrespective of profession and leisure purCorrespondence to: DS.

suits, all will still wish to perform delicate tasks, such as

writing and doing up buttons and fastenings, will touch
their spouses and their ospring, will be disturbed by an
unattractive extremity on display.
The overlay of compensation for work injuries frequently constitutes a complicating factor, both in the
planning and timing of reconstruction and in the evaluation of outcome.
The growing hand presents special challenges, with
the requirement for constant remodelling of the skin investiture and skeletal element. Scarring and contractures will interfere with these processes and must be
taken into account when selecting methods of repair. To
these priorities must be added the factor of parental anxiety and possible guilt feelings following accident.
It is unfortunate that management of ngertip injuries
is frequently downgraded in the list of surgical priorities,
is considered trivial and meriting little surgical input.
Often their complexity and functional signicance is
poorly appreciated and management delegated to inexperienced members of the surgical team. Selected
treatment options all too often reect this low key approach, with methods adopted which lead directly to
long-term morbidity.

ASSESSMENT
The repertoire for reconstruction available to the hand
surgeon in the management of ngertip injuries is large
and expanding. All surgeons will have their favourite
methods and tendencies. It is important, however, constantly to keep in sight the desired outcomeFthe reconstruction of a ngertip with as near an appearance
and functional versatility as the original. Many untoward
results come not from poorly executed surgery but from
poor selection due to one or more of a number of
causes:
(a) The signicance of the injury may not have been
apparent.

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CURRENT ORTHOPAEDICS

Figure 1 The main forms of grip pattern: (A) power grip; (B) key grip; (C) pinch grip; (D) and (E). chuck, three-point or tripod grip.

(b) The managing surgeon did not have it in his/her

repertoire to apply the indicated method.
(c) The managing surgeon had the required expertise
but was wedded to a small number of favourite
methods and applied one that appealed rather than
one which was indicated.
In the eld of reconstruction, there are no recipes, only
principles. Knowledge of the functional signicance of a
particular injury will provide an assessment of the scope
and timing of the required reconstruction. One should
attempt to master most methods, be willing to change

plan and to consider modications.This approach will enable the managing surgeon to select the appropriate
course and customise each reconstruction to provide
the best outcome possible on the day.
In assessing an injury it is useful to recall the main patterns of grip adopted by the human hands (Fig. 1). Power
grip and key grip are strong methods of prehension, but
relatively imprecise, depending on movement at proximal joints and animated by large muscle groups. More
precise forms of grip, including chuck, or three-point,
grip, involve the ngertips as prime points of contact.
The dexterity of these forms of grip depends on what

FINGERTIP INJURIES

273

homodigital, but possibly heterodigital.The secondary

defect (on low premium skin) might be acceptably
resurfaced with a skin graft.

Figure 2 The leading edges of digits and thumb (high premium areas).

one may call the peripheralisation of movement, with all

action occurring at small, digital joints powered by precise, ne, intrinsic musculature. This principle is best exemplied by the posture of writing, where the elbow,
wrist and ulnar aspect of the hand are all steadied on
the writing surface, while all movement occurs at digital
joint level.
The more peripheral the movement, the more the ngertips come into play. An inadequate or painful reconstruction will aect these activities worst of all.
Although one would not suggest that any part of the
hand is unimportant, one can regard the hand as a map
of functional units. Natural functional posture and main
patterns of grip dictate that most digits can be considered to have a leading and a trailing aspect, which become high premium and low premium areas of skin
cover respectively (Fig. 2).
The thumb is the best example of this aspect of analysis. The ulnar pulp leads and is involved in virtually all
dextrous activity, since it is this area which faces the long
digits most directly. By contrast, the radial pulp trails
during all but unspecialised tasks, such as tapping on a
horizontal surface. The index and the ring nger can be
said to have less marked dierences between their leading and trailing aspects.
Using this model in the analysis of a specic injury one
tends to a number of considerations:
K

Injury of high-premium areas requires the best

reconstruction, preferably like with like, comprising
sensate, glabrous pulp skin, taken, if possible, from
the same digit.
Injury of alow-premium area, such as the trailing edge
of the thumb, may be reconstructed acceptably with
relatively non-specialised cover, such as a skin graft.
It is logical to consider reconstructing the leading edge
of a digit by transferring trailing edge pulp, preferably

These observations are not absolute.They are oered as

some of the factors one should consider in assessing the
signicance of the injury and in selecting a method of reconstruction.To this analysis must be added factors such
as special requirements for a particular patient, such as
the playing of musical instruments, typing on keyboard,
patient compliance.This review is not concerned with injuries to other structures such as bone, joint, tendon. It
need hardly be mentioned that injury to these structures
must also be taken into account in the assessment of any
injury.
Bearing these principles in mind, what follows is
an account of the various main methods of reconstruction of skin cover, along with some points pertinent
to selection, advantages and disadvantages, as well as
some points of technique. It cannot be overemphasised
that the method selected must suit the defect and
the level of expertise of the surgeon. In this regard,
one must mention that it may be appropriate to select
a temporary method known to be insucient for
long-term wear (such as a dressing or split skin graft),
but leaving all options open for reconstruction on another day and with the availability of the appropriate expertise.

DELAYED HEALING
The skin cover of the hand has remarkable powers of regeneration as is evidenced by the reliable healing of the
open palm technique advocated by MacCash. Simple
dressing of a pulp wound must not be regarded as management by neglect (especially by the patient who must
be warned that this method requires careful adherence
to instruction and compliance with treatment). The patient must also be informed that this method involves
considerable delay (a pulp defect 1cm3 will take an average of 4 weeks to heal). A number of factors must be
observed:
1. The defect must be appropriate for this method of
treatment. Relatively large pulp defects, even with
signicant loss of pulp volume, are appropriate,
provided no vital structure is exposed. These include:
tendon (which will granulate and lose all gliding
planes), bone and joint. Severely contaminated or
crushed defects are not suitable unless they are
thoroughly debrided of all contamination and
necrotic tissue.
2. The hand must be elevated.
3. Non-adherent dressing requires regular replacement,
preferably on alternate days. There are exceptions to
this: in children it is routine to leave such dressings for

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CURRENT ORTHOPAEDICS

1 week; it is often possible to leave the wound

exposed after this period of dressings in order to
avoid further painful changes.
4. The dressing should be light and permit mobilisation,
which will help reduce oedema.

shape to the stump. One should never be tempted to suture exor and extensor tendons together over the edge
of thenger; this invariably leads to an imbalance between the two tendon systems and most often a exion
contracture.

It is common to dress such wounds with Tulle gras

(paran gauze). This dressing has the virtue of low cost
and widespread availability. Its use is hallowed by tradition. It tends to encourage inammation, tends to dry rapidly and to adhere more than one might expect, with
consequent pain in dressing changes. Many, better alternatives are available such as thin, perforated, silicone
sheeting. Dierent surgeons will have their preferences,
but the ideal dressing will be non-adherent and will form
a barrier to contamination.

SURGICALOPTIONS FOR COVER

TERMINALISATION
In cases where a signicant part of the distal phalanx is
crushed, possibly with accompanying disruption of the
nailbed and/or the distal interphalangeal joint, amputation, with closure using locally available skin, may be the
only option. In such cases it may be appropriate to elect
to ablate the nail which, regenerating, will be unsupported, unattractive and lead to functional problems
such as snagging.
Amputation seems a seductively simple option which
would appear to be straightforward and easily performed. Much morbidity results from amputations performed without proper regard to points of technique.
In selecting the level of amputation, one must bear in
mind the quality of skin cover obtainable considering
what is available. It is better to elect for a shorter length,
with good quality, mobile, skin cover, than to preserve
length at all costs but provide poor quality skin cover,
which will be tight and painful. A digit with tense, painful
skin cover may well be excluded from function, resulting
in an eective loss of all length.This is particularly true of
the index, which is readily substituted by the middle nger. Many such digits require subsequent revision. They
may also prove remarkably dicult to restore function
and to render free of pain, once the cycle of tenderness
and exclusion has set in.
Because dorsal skin is relatively elastic, the scar tends
to come to lie on the palmar aspect.Unless care has been
taken to mobilise the nerve ends and place them in a dorsal position, the stump neuromata are trapped in palmar,
contact skin. It is useful to preserve the insertion of the
FDP tendon if this is possible since this will increase the
power available to this digit. If it is necessary to amputate
through the DIP joint, it is best to taper the middle phalanx by removal of the articular cartilage and the bulk of
the condyles so as to avoid an unattractive, spatulate

If delayed healing is not the procedure of choice, the

options for cover include:
(a) Skin Graft and (b) Flap cover.
A skin graft can be dened as a segment of skin harvested from a remote area, transferred to a defect and
requiring nourishment from the recipient bed for survival.Graft Take is dened as the establishment of a blood
supply to a graft.
A ap can be dened as a segment of tissue on a pedicle, which provides the ap with blood supply.
The essential dierence between these two forms of
cover is the fact that the ap brings its own blood supply
and can be applied on hostile territory while the graft is
totally dependent for nourishment on the blood supply it
nds at the recipient bed. Whichever other considerations are taken into account in deciding for one or the
other (cosmesis, sensibility, function), this overriding
principle must be respected.
(The delayed ap rather straddles this classication
since it is raised on a vascular pedicle but inset into a recipient area in the expectation of the establishment of a
blood supply from this new site.The rationale for its use
is outlined below).

Skin grafts
In considering cover of a defect with a skin graft the surgeon poses a number of questions:
1. Is the defect capable of vascularising a graft and
ensuring take?
2. Is the graft intended to provide temporary or
permanent cover?
3. If the skin graft is intended to be permanent, will the
functional outcome be good? What type of skin graft
should one select?
Awound permitted to heal by secondary intention will
contract to a variable extent. Skin grafting can be considered as a method of inuencing this healing process.1 A
skin graft will discourage this contracture in proportion
to the thickness of graft.
Provided the bed will ensure take, a split skin graft
provides an excellent and prudent form of temporary
cover. Many wounds involve bursting or crushing mechanisms. Despite assiduous debridement at presentation, one encounters many situations where there is

FINGERTIP INJURIES

contusion, oedema or when one opts to leave tissue of

doubtful viability with a plan to return for second look
surgery. In such situations, local aps may be the chosen
denitive cover but their territory is itself involved in the
area of trauma. Raising a ap in such a situation may
lead to necrosis and failure as well as waste an
option that might be possible at a later stage when all
eects of trauma have settled. A skin graft will provide
comfort, initiate the healing process and will keep all
options open.
In some situations, a skin graft constitutes appropriate
denitive cover. These include the trailing aspects of the
digits and the secondary defects left by the raising of
local aps.
Skin grafts are inappropriate in areas requiring accurate, pain-free sensibility with mechanical cushioning approaching that of normal pulp. Numerous studies have
conrmed that skin grafts in such situations result in unacceptable hyperaesthesia, poor cosmesis and troublesome ssuring. In many such cases, conservative
management with dressings may be considered a preferable option provided the relevant criteria apply, or one
may resort to ap cover.
The choice of skin graft lies between split and full
thickness skin. With regard to donor site surgeons
dier in their preferences; some consider that a distant
site is preferable, since this can be concealed and/ or
revised by excision and suture into a linear scar.
Others favour keeping the site of injury limited to
the hand so as to enable elevation of all aected areas.
The author favours the hypothenar eminence of the
same hand for small split skin grafts, the upper forearm
for larger grafts (with a view to subsequent revision). Full
thickness grafts can be taken from the cubital fossa skin
crease if small and from the (non-hairbearing) groin if
large.One must not lose the opportunity to harvest skin
graft from any tissue that is to be discarded and thus
avoid a donor site altogether (the concept of the Bank
Digit).2

Some points of technique

275

Excessively thick grafts taken from this site may produce

troublesome discomfort in a scar which comes to lie in
the landing pad of the writing hand.

Full thickness grafts

If a full thickness graft is required, one should avoid
harvest from the wrist crease since scars placed
here can look like the outcome of self inicted wounds
and can prove tender when watches or bracelets are
worn.
The cubital fossa usually provides ample skin and
in the same tourniquet site, which speeds proceedings and makes harvest of a good quality graft
more accurate. It should be cut to an accurate template
to t the defect. The graft should be taken thin,
with a minimum of subcutaneous fat. When applied to
the defect, it is advisable to secure the graft using some
form of compressive dressing such as foam dressing sutured round the edge of graft or a traditional tie-over
dressing.
With regard to selection between full and split thickness grafts, the choice is a matter of balance between a
number of factors. A full thickness graft requires a better
quality bed since there is a larger cell population to nourish. Take of a split thickness graft is more reliable. Conversely, split skin grafts contract more signicantly than
full thickness grafts, a factor of importance in mobile
areas crossing joint creases and certainly in the growing
hand.
Finally, one may mention the composite graft as a form
of skin grafting. This is especially applicable in the childs
hand, when the section is clean and is more successful
the younger the child and the fresher the injury.The amputated part must be applied rapidly, with a minimum of
dissection to either surface and with as accurate an alignment of landmark points (nail fold, etc.) as possible. Parents are warned that the method is not guaranteed and
that the part often appears to mummify and perish only
to reveal acceptable preservation of structure some
three weeks later when the carapace is carefully removed.

Split skin grafts

A guarded skin graft knife such as the Watson or Silvers
knife is preferable. The method described by Venkataswami for harvest of hypothenar skin grafts produces
good cosmetic results and good quality dermis.The graft
blade is set thin. The rst sweep generally harvests
keratin. This layer is left attached and the blade withdrawn carefully. The next sweep of the graft blade takes
the deeper layer of dermis and harvests this free for
transfer.The attached keratin layer is then replaced over
the defect and can be glued or ne-sutured in place. It
provides good pain relief and frequently undetectable
healing.

FLAP COVER
In many situations ap cover is required. These could be
summarised thus:
(a) When deeper structures are exposed, e.g. bone,
joint, tendon, nerve. In some situations, a skin graft
will be chosen for application directly on to intact
tendon sheath or paratenon, or directly applied to
cancellous bone where, somewhat surprisingly it
frequently takes, but these are relative indications;
by and large, exposure of such structures requires
ap cover.

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CURRENT ORTHOPAEDICS

based on their provenance.Other classications concentrate on the vascular pattern, as inrandom and axial pattern. In addition to these well-established classications,
it is useful to classify aps in the hand as sensate and insensate.The division between the two is somewhat arbitrary, since many aps that are transferred without a
nerve supply do achieve sometimes a remarkable degree
of re-innervation. By and large this is unreliable, despite
the many series that record return of two-point discrimination in such aps. It is a useful working premise to
consider insensate those aps which replace pulp with
skin taken from areas other than pulp, whether a nerve
is transferred with the ap or not. Flaps consisting of
pulp taken with their nerve of supply can be expected
to achieve discriminatory sensation comparable to normal pulp.
Using this method of analysis, one can classify the
main available aps thus:
Insensate aps include:
Kite ap and
Delayed aps:
Cross-nger aps,
Thenar aps,
Distant aps, e.g. groin aps, random aps.
Sensate aps involve pulp transfer, homodigital, heterodigital or free. A list of these would include:
Figure 3 The two main designs in digital aps: (a) leaving
the vessel undisturbed in the base of the ap; and (b) isolating,
dissecting the vessel and islanding the ap.

(b) When deep structures are not exposed by the injury

but sensibility, mechanical quality or cosmesis are
important requirements.

General principles of ap design in the digits

Preservation of continuity of blood supply to a ap is
paramount. All designs must full this basic, absolute criterion. In general terms, this vascular supply may be
(a) left undisturbed in the skin, as in the rotation ap of
Hueston and the cross-nger ap (Fig. 3A), or
(b) formally dissected clear, as in the islanded aps
(Fig. 3B).
The latter type of designs are more mobile and more
versatile.
Flaps such as the V-Y advancement ap may be dissected and advanced forward without formal identication of the pedicle, as in the rst design, or be islanded on
two, dissected pedicles as in the second design.
Flaps can be classied in a number of ways. Conventional classications into local,regional and distant are

V-Yadvancements (Tranquili-Leali,3 Atasoy,4 Kutler),5

Thenar advancement aps (Moberg),6
Rotation advancement (Hueston),7
Bipedicled homodigital (OBrien),8
Homodigital (Segmuller,9 Venkataswami,10 Joshi,),11
Heterodigital (Littler),12,13
Free aps e.g. hemi-pulp transfer from toe or bank
digit (Foucher).2
One should reiterate that this is a working
classication, sorting aps rather too harshly on
the basis of their sensibility.To name one example, many
studies have recorded the recovery of excellent
two-point discrimination in the cross-nger ap.14,15
These results are remarkable considering that the population of sensory end-organs in dorsal skin never matches
that of pulp skin. In practice, the neurovascular island
aps oer the best quality of skin with the right mechanical and sensory qualities to replace pulp and it is these
aps that should form the standard by which others are
assessed.
Our methods of assessment of sensory discrimination
remain relatively crude. The two-point-discrimination
test, testing with Semmes^Weinstein bres, vibration
tests and others, are subject to signicant operator
variability and subjectivity. This may go some way to
explaining the wide variation in reported outcome of
sensibility attributed to the various methods.These contradictions will be resolved when we have available

FINGERTIP INJURIES

Figure 4 The Kite ap from the dorsum of the index to reconstructthumb pulp.

reliable, objective and reproducible methods of such

assessment.
None of this discussion is intended to diminish or advocate any particular types of aps. All these methods
have merit and it is a wise surgeon who remains ready
to draw upon any of these techniques as required, without dismissing any as terminally awed. It is also fair to
point out that a so-called insensate ap performed meticulously and skillfully by a surgeon familiar with the technique is innitely to be preferred to the technically
demanding sensate ap performed, for otherwise
correct indications, by a surgeon ill at ease with the
procedure.
This paper does not permit an exhaustive description
of all techniques including their merits and drawbacks.
A brief section will be devoted to each with
important features of selection, technique and expected
outcome.

Insensate aps
Kite ap (Fig. 4). The kite ap was christened thus by
Foucher (Le lambeau cerf-volant) who rst islanded
the ap taken from the dorsum of the index nger originally described by Holevitch and modied by narrowing of
the skin pedicle by Vilain and Michon.16 A skin ap is
raised, at the level just above the extensor tendon paratenon, on the rst dorsal metacarpal artery and including any detected branches of the cutaneous radial nerve.
This ap is completely islanded on artery, supercial vein
and nerve branches and will reach and replace thumb
pulp.
It is included in this section on insensate aps despite
the fact that radial nerve branches provide a form of sensibility. Although it provides good protective sensation
(and sometimes remarkably good discrimination), it does
not, as a general rule, match the discriminatory level
found in normal thumb pulp especially on the ulnar
aspect.
Important points of dissection include: Early identication of the rst dorsal metacarpal artery and careful
dissection of its origin from the radial artery at the base
of the rst dorsal interosseous muscle. The artery

277

frequently follows a path deep to the aponeurosis or fascia of the rst dorsal Interosseous,from which it must be
carefully freed. If the ap is tunnelled, this tunnel must be
generous and provide no compressive or restraining
pressure on the pedicle.
Advantages: The procedure is completed in a single
stage and is technically unchallenging. The skin harvest
from the dorsum of the index proximal phalanx produces
no functional impairment.The pedicle is long and the ap
easily reaches its destination, with or without tunnelling.
The transferred skin retains some sensation.The secondary defect on the dorsum of the index is produced surgically and, with care, should yield a good bed capable of
nourishing a graft very well.
Disadvantages: The thin dorsal skin is a poor substitute for the glabrous pulp skin. Sensory discrimination is
poor, but present provided one is careful in dissecting
and handling the ne and poorly supported radial nerve
branches. In coloured races the dorsal skin will be dark
and stand out on the pulp of the thumb. In all patients,
particularly males, a variable amount of hair growth persists in the ap. The donor site requires a full thickness
graft, which usually takes and blends well but may provide poor cosmetic cover.
Delayed, or staged, aps
The principle ofdelay: Delayed aps have a random design, i.e. are not planned over a known vascular pedicle.
They are transferred either immediately or after an interval. They are inset into the recipient defect and left
for a period until they establish a new blood supply from
this new site.They are then divided from their donor site.
The technique has its origin in the early days of Plastic
Surgery when little use was made of axial pattern aps.
The relative ischaemia produced by part detaching a section of tissue, eectively boosts the blood supply provided by the pedicle but also acts as a stimulant for new
blood vessels to grow from the recipient bed into the
ap.The period required before the ap can be safely detached from its pedicle of origin varies, but generally depends on the quality of blood supply of the recipient bed
and the volume of the ap.
(a) Cross-nger ap (Fig. 5). The rst report of the cross
nger ap was by Gurdin and Pangma.17 Since that time
and until the advent of homodigital islanded aps, as well
as the use of microsurgical techniques, this ap has been
something of a workhorse in the repertoire of nger tip
reconstruction. It is still a popular ap.
Important aspects of the technique include: Thorough
debridement of the defect to be reconstructed followed
by a careful assessment of the size and shape of this defect. This will enable accurate planning and design of the
donor ap. The ap should be designed to lie between
joints over the dorsum of a phalanx.

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CURRENT ORTHOPAEDICS

unless modied as in the method of Venkataswami,

which is technically demanding.17 Other modications,
such as the technique of coapting the dorsal digital nerve
to the stump of the digital nerve in the recipient nger
have not made the ap any more popular nor delayed its
relative decline.
The ap has been largely displaced from the rst-line
choices for reconstruction since there are now many suitable sensate aps with fewer disadvantages. It is indicated when other options are unavailable (as in
simultaneous trauma to multiple sites in the hand) or
for more proximal volar defects where sensory discrimination is not required to the same extent.

Figure 5 The cross-nger ap.The secondarydefectisresurfaced with a full-thickness graft.

Careful dissection of the ap so as to raise it undamaged while at the same time leaving behind a secondary
defect that can accept a graft. The design must be such
that the defect in the nger tip can easily and comfortably be implanted into the ap which is turned over like
the page of a book.
The full thickness graft is best sutured into the secondary defect before the ap is inset since it is easier to gain
access and suture accurately while the ngers are still unattached. Some of the graft should extend on to the pedicle of the ap so as to avoid exposure of raw surface.
Once the ap is inset, a customised splint is fashioned
to maintain the position of the digits. This splint should
be removed as early as possible (after a few days so as
to enable supervised mobilisation of the ngers).
There are a number of variations to the standard
technique including the innervated neurovascular crossnger ap from middle nger to thumb and the reverse
dermis cross nger ap.17,18
Advantages: Relatively cheap skin is used to reconstruct a more valuable territory. The ap is reliable, simple to perform and versatileFmultiple cross-nger aps
can be performed including combinations where the
same nger supplies and receives a cross-nger ap at
the same time e.g. dorsum middle nger to palmar index
combined with dorsum of index to thumb pulp.
Disadvantages: A period of some 2 weeks between
raising of the ap and division.This will produce stiness
in the PIP joint particularly in brawny, thick-skinned
hands and require physiotherapy to reverse. Pigmented,
hairy skin may be unsightly on the pulp (the full thickness
skin graft to the dorsum frequently blends remarkably
well). A skin graft is required.The ap is totally insensate

(b) Thenar ap (Fig. 6). First described by Gatewood but

popularised by Flatt, Beasley and Lluch.19^22 Smith and
Albin modied the donor site, moving it to the base of
the thumb and fashioning the ap in the form of an H
(Fig. 6A).23 They aimed to avoid skin grafting by advancing one ap of the H after harvest. Others have rened
the original technique, designing the ap as a double
Bishops Mitre, so as to fashion a realistic looking pulp
and surfacing the secondary defect with full thickness
skin graft.22
Technical points: Since the recipient digit tip is to be
left attached to the thumb it is essential that the defect
should reach the ap origin comfortably and free of tension. It is preferable to use designs which place the donor
site at the radial aspect of the MCPJ crease of the thumb
as originally described (Fig. 6B), rather than the base of
the thenar eminence. This keeps to a minimum the exion required of the recipient digit and places the donor
site away from the grip contact area.
Advantages: The ap can be applied to the tips of index, middle or ring ngers. The transferred skin can be
made quite bulky and fashioned to give a good cosmetic
result on the recipient tip. The donor site is relatively
cheap and trouble-free particularly if various described
technical details are observed.
Disadvantages: Practically invariable stiness in the
recipient nger with a residual exion contracture. This
can be minimised by avoiding the ap in the aged and by
leaving the ap attached for the absolute minimum time
(usually safe to divide by 10 days post-op). It is wise to institute prompt physiotherapy as soon as the digit is detached without waiting for the patient to present after
an interval.
The ap is insensate, a signicant drawback in an index
tip which is so easily left out of multi-digit tasks and substituted by the middle nger.The donor site can be troublesome and the site of hypertrophic scarring. Methods
which attempt to produce (usually tense) primary closure of the donor site, and procedures where an applied
skin graft fails, are more likely to produce a tender scar.
Meticulous technique ensuring full take of a good full

FINGERTIP INJURIES

279

Figure 6 The thenar ap: (A) The design of Smith and Albin.The H-ap. After division, one limb of the H is advanced to close the
defect without graft. (B) The original design of the thenar ap, sited on the radial aspect of the MP joint level.

thickness graft, and choosing a ap donor site remote

from the grip contact area will minimise this possibility.
(c) Distant, delayed aps. The disadvantages described
for the above insensate aps hold true for distant aps
with the additional problems of immobilisation and diculty with elevation of the hand. Nevertheless, occasional cases require the raising of a random skin ap on
the inner aspect of the arm, in the inframammary fold,
or in the groin crease.The indication would include multiple defects or practically denuded digits devoid of skin
cover.There is still place for the groin ap to invest a degloved or amputated thumb, most commonly in preparation for free toe transfer at which time one is pleased to
have ample surface of good quality groin skin around the
thumb base.This provides better quality cover and much
easier dissection than scarred and indurated tissue from
the original crush injury.
Occasionally, a groin ap will be selected to provide
denitive cover of a degloved thumb with an otherwise
intact skeleton and tendon apparatus. Sensibility can be
improved at a later stage, by means of a pedicled neurovascular island ap, from the same digit, from the ring
nger by the procedure of Littler, or by free pulp transfer. The indications for these latter methods have diminished as microsurgical techniques of transfer of whole or
part toes have become more established and reliable.

Sensate Flaps
(a) The V-Y advancement ap (Fig. 7) In the Anglo-Saxon
literature, this ap is frequently associated with Atasoy.4

Figure 7 The Atasoy V-Yadvancement ap. Note the extensive dissection to produce an island ap. Suitable amputations
must be transverse or dorsally angulated.

In fact precedence, of sorts, can be claimed byTranquiliLeali, a surgeon in Bologna, who published in the Italian
literature a detailed description of the technique in1935.3
The original description included the procedure of ligating and dividing both digital bundles, permitting survival
of the triangular ap via its connections to the volar aspect of the phalanx. Movement was a matter of forward
shear, the thick ap shearing forward rather like a jelly.

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CURRENT ORTHOPAEDICS

Figure 8 The Moberg thenar advancement ap: (A) the original design, requiring exion of the IPJ; (B) Modication to increase
advancement while closing the secondary defect.

This technical detail would appear to have missed translation into the English literature and most have practised
moving the ap forward, practically islanded on intact
digital vessels (it is drawn thus in the illustration). In fact
this ap works best as a bipedicle island, a point reiterated by Lister.
Selection of the appropriate case is crucial to success.
Only transverse or dorsally orientated defects are suitable. At least half the distal phalanx should be present if
one is to avoid loss of support and development of a
hooknail.
Points oftechnique: The ap is designed with the width
of the advancing edge precisely corresponding to the
width of the nail.Too narrow a ap and the healed result
is a digit tip with what appear to be rather unattractive
shoulder pads. Too wide and the tip will have a broad,
spade-like appearance.
It has been maintained that the proximal apex
of the V should be at the distal interphalangeal
joint crease. This is not essential, nor always possible. The apex can extend proximal to the crease and
the ap released as usual. The segment of advanced
crease will disappear over a period of months and a new
crease will form corresponding to the exion point of
the joint.
After the ap inset has been completed, one must
wait patiently for colour to return to the triangle. It is
sometimes necessary to release a stitch at the base (the

stem of theY), but never at the advancing edge since this

will invariably cause retraction of the ap and exposure
of the bone tip which will later heal with a tender and
unsightly dimple.
Kutler described bilateral V-Y advancements, subsequently modied (and designed larger and safer) by
a number of workers.5 Each of these aps is raised
on a single vascular bundle. Technically, these aps
are more demanding than the single palmar V-Y for
two reasons: (a) They overlie Clelands ligament and require more assiduous division of brous septa and (b)
The anatomy of the vascular bundles is variable beyond
the DIPJ crease with some digits exhibiting a U-shaped
vascular arcade, others a Y shape and still others an H
shape.24

(b) Thenaradvancement (Fig. 8) Described by Moberg this

ap raises the entire palmar surface of the thumb which
is then advanced to cover a transverse or dorsally orientated defect.6 This advancement is aided by exion of the
interphalangeal joint. Dissection of the ap is carried
down both midlateral lines and proceeds on the surface
of the exor pollicis longus sheath, including in it both
digital bundles. It is an important anatomical point that
the thumb digital bundles lie immediately to either side
of the FPL sheath and not down the mid-axis of the
thumb as in other digits.

FINGERTIP INJURIES

It is the specic anatomy of the thumb which makes

this ap possible, since the thumb consistently enjoys
dual blood supply with an independent source to the dorsum, given o by the radial artery before entering the
palm (the arteria princeps pollicis). Snow has advocated
use of this ap in other, long digits.The risk of necrosis of
the dorsal skin in the long digits is signicant.25
The ap does not truly advance, but depends on the
release of tethering septa between skin and deeper tissues, to enable creep. The same skin then stretches and
covers a longer area, aided in no small way by exion of
the IPJ, which frequently inherits a permanent exion
contracture as a result.
Advantages: The main advantage of the ap is its perfect sensibility, without recourse to re-education. The
midlateral lines of suture heal very well.
Disadvantages: The main drawback is the exion contracture of the IPJ. In an attempt to increase mobility of
the ap, Elliot et al. extended the midlateral incisions
proximally and brought them to meet in the midline
(Fig. 8B). Eectively this turned the ap into a large V-Y
design, more mobile and capable of advancing over the
tip of an extended thumb.

(c) The advancement rotation ap (Fig. 9) Hueston

described this ap, based, without islanding, on one
digital bundle and rotated to cover the ngertip.7
The design works best with oblique or transverse
amputations.
The technique utilises a square or rectangular ap
raised by an L-shaped incision extending down the midlateral line and transversely across the palmar surface of
the digit, to create a ag shape.The digital bundle on the
side of the midlateral incision is not included in the ap.
The dissection plane proceeds close to the tendon
sheath and extends to the digital bundle on the static
edge of ap (the pedicle). It is advisable to divide Clelands
ligament on this static edge since this will facilitate rotation of the ap (Fig. 9a).
The original technique provided ample skin cover but
was criticised on a number of counts: the leading, free
edge of the ap is separated from its nerve supply and is
thus insensate; the distal corner of the static edge develops an unsightly dog-ear; The pedicle that is left behind
can develop a painful neuroma in an area of high
contact.
Modications have been proposed to address these
perceived limitations: Souquet proposed advancing the
pedicle with the free edge of the ap.26 Although this
keeps the entire ap sensate and also transposes the
neuroma dorsally, the ap is far less mobile and depends
for its arc of rotation on mobilisation of the nerveFa
limited exercise yielding only a short distance. This is
best reserved for oblique defects, which require little
movement.

281

Foucher proposed an alternative approach, suggesting

raising the ap as described by Hueston (one NV bundle)
but basing the static side on the leading pulp.27,7 The insensate half of the ap thus comes to lie on the trailing
pulp.
The unsightly dog-ear was also addressed by Foucher
by proposing excision of a square area of skin from the
dorsum, folding the ap corner to inset into the defect
(Fig. 9B).
The secondary defect needs no cover, but can be
safely left to heal by secondary intention. More rapid
healing can be obtained with a small split skin graft, or a
triangle raised in the axis of the digit and turned to t
into the triangular defect.
The bipedicle homodigitalisland (Fig.10) OBrien described
this, eectively the rst of the homodigital island aps,
for the cover of transverse or volar amputation of the
digits.8 He included in his indications the replacement of
terminal scarring on the ngertip, the replacement of insensate skin or poor quality skin and the treatment of

Figure 9 The Hueston advancement rotation ap. Note

plane of dissection. (A) Clelands ligament on the base of the ap
should be divided to produce easier rotation; (B) Modication of
Foucher to deal with the dog-ear.

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CURRENT ORTHOPAEDICS

Figure 10 The OBrien bipedicle homodigital ap. The secondary defect can be resurfaced with a split skin graft, or triangular aps.

stump neuromata, the ap enabling the nerve ends to be

advanced to a dorsal position.
The ap is a natural progression from the Moberg ap
described four years earlier. In order to gain greater mobility, the midlateral incisions were joined transversely
thus enabling dissection and a complete islanding of the
ap which advanced distally.
Points oftechnique: These particularly concern the dissection of the pedicles.There are no formal veins accompanying digital arteries. All islanded digital aps depend,
for their venous drainage, on the delicate plexus of vessels in the connective tissue surrounding nerve and artery. It is important to raise these pedicles fatty and
avoid excessive skeletonisation. Fibrous strands can and
must be divided to enable the pedicle to stretch, but
the fat surrounding the vascular pedicle should be little
disturbed.
The ap pedicles should be dissected enough to enable
easy travel to the defect, usually around the tip of the
digit. One should not resort to exion of the nger simply because the ap will not reach, for want of further
dissection. Nor should one need to protect the ap by
exing the nger post operatively.
The secondary defect may be skin grafted or resurfaced using two triangular aps, one on either side, and
crossing them to ll the secondary defect. These aps
may be tight and it is generally safer to use split skin
graft, or to leave the defect to heal by secondary intention if it is small.
(d) Homodigital Island aps (Segmuller, Venkataswami, Joshi,
Evans) (Fig. 11) Segmuller proposed islanding the Kutler
pulp ap in order to increase its mobility. Once the principle of islanding half the area of the pulp had been established, numerous other authors produced modications
on the theme.Venkataswami described transfer of an oblique, lateral island, Joshi described a ap that uses predominantly dorsolateral islanded skin.Foucher described
a number of modications, including: (a) the exchange island ap, (b) the procedure of dividing the digital nerve

Figure 11 The homodigital, island advancement ap.

Figure 12 The Evans step advancement island ap.

and reanastomosing it to the nerve in the recipient defect and (c) the technique of anchoring the ap using a
trans-skeletal needle to minimise sutures and venous
congestion.10,11,28 ^30 Glicenstein proposed a retrograde
vascularised island ap, conceived on the principle of retrograde perfusion in the forearm as in the Chinese Radial forearm ap. Finally, Evans designed an ingenious
version, the step advancement island ap which utilises
a series of triangular aps to move forward and interdigitate with the created defect, closing the proximal secondary defect directly (Fig.12).
The principle of design is common to all these variations: a suitable island of skin is designed, able to ll the
defect.The vessel and nerve supplying this skin territory
are identied and dissected proximally until enough
advancement has been obtained to cover the defect
without tension. This dissection may be carried very
proximally, with additional length obtained by ligation
and section of the vessel to the adjacent digit at theY bifurcation and by careful longitudinal separation of the
digital nerve from the common digital nerve. The maxi-

FINGERTIP INJURIES

Figure 13 Advancement of the neurovascular bundle.

Figure 14 Advancement of the neurovascular island slap.

mum advancement is obtained on the radial aspect of

the index where the digital bundle is tethered at the radial base (Fig. 13). Release of this tethering will produce
an extra advancement not possible in other digits. In the
index a maximum of 22 mm advancement can be obtained, aided by medialisation of the pedicle.
Most stretch is obtained from the pedicle, little from
the skin island. A ap designed with a small island and a
long pedicle will advance further than one with a large
island and a short pedicle (Fig. 14). The ap with the largest skin island and shortest pedicle is the Evans ap
which advances a relatively short distance and therefore
needs careful planning and selection.This is especially important in this ap which predesigns a series of aps to
ll a row of secondary defects and one is, therefore,
committed to the expected advancement from the
start.
Advantages: All islanded aps have a degree of mobility and versatility not enjoyed by the more xed, rotation or advancement aps as those described above.
Since the digital nerves are advanced in the ap, sensibility should be unaltered although most will go through a
variable phase of hypo- or (more usually) hyperaesthesia.
Since the ap is homodigital there are no problems with
cortical reorientation. The blood supply of the ap is
ample and will serve to nourish a poorly vascularised
nger tip.
Disadvantages: Islanded aps are technically demanding and many will be daunted by the dissection required
and their apparent precarious attachment to a nourishing pedicle.There is a tendency for the nger to ex and

283

for a exion contracture to develop.This complication is

not dicult to avoid. It is important to select the case
well. One must not ask of a ap a distance of travel,
which it is unable to provide. Many times the problem lies
in an insucient, tentative, dissection, with residual taut
bres preventing a relaxed stretch of the artery and
nerve. Dissection of the pedicle is a balance between division of all restraining bres and possible compromise
of the venous drainage, as has been mentioned above.
There is a natural reluctance to hold back on proximal
dissection although in the long run this temerity will
place the ap at greater risk.
(e) Heterodigital Island ap. This ap, originally described by Littler in 1953, consists of an island of skin taken from the ulnar aspect of the ring nger and
transferred to the ulnar aspect of the thumb.12 It was
proposed to provide sensate skin to the osteoplastic
thumb reconstruction (free iliac bone graft invested in a
random abdominal ap). The principle of transferring an
island of skin from one digit to another was later extended to the long digits.6,13
Important aspects of technique include: careful dissection of the raised island, following the pedicle back
to the palm. Extra length is gained by dividing the arterial
branch to the adjacent digit supplied by the same common digital artery, and by teasing apart the nerve elements from the common digital nerve. Once again it is
vital that the fatty investiture of the neurovascular pedicle be left intact. The ap should be tunnelled through a
generous space and inset free from tension.
The Littler heterodigital transfer has been criticised
for an apparent deterioration in sensibility over time.
This has largely been attributed to a tight tunnel or progressive scarring around the pedicle.Furthermore, most
patients will not develop any cortical reorientation and
will continue to refer sensation in the reconstructed
thumb/digit to the donor digit.
Foucher has proposed transferring the island as originally described, but dividing the digital nerve after
transfer and anastomosing it to the recipient nerve on
the thumb.28 In the younger patient in whom a signicant
proportion of sensation will return following nerve repair, this gets around the problem of deterioration in
sensibility and also the cortical reorientation problem.
Unfortunately, it is the older patient who has a less plastic cerebral cortex and who will suer the most resistant
cross-referral of sensation.
This ap is now rarely indicated since there is available
a good repertoire of choice between sensate homodigital aps and free pulp transfers.The amputated thumb is
routinely reconstructed by means of one of the several
types of toe transfer.
The rationale of the technique remains useful particularly in situations of multi-digit trauma where a damaged
nger is destined for amputation but may still be capable

284

of donating an island ap to an adjacent digitFanother

example of Fouchers Bank Digit.
The various forms of micro-surgical transfer will not
be discussed since they form the subject of another article in this issue.

CONCLUSION
1. Assessment of the defect is crucial. Only by dening
the extent and complexity of the reconstructive task
can one begin to consider choice of reconstruction.
2. The managing surgeon should master as many
techniques as will cover the various types of defect.
During ones period of training (and beyond) it is
important to learn from reconstructions which fail
to produce an acceptable result, question the cause
of such an outcome and if this identies a deciency
of repertoire one should seek to rectify this. Only
by doing so will one eventually be equipped with
a comprehensive range of techniques. One must
caution, however, that many of these methods are
enticing surgical exercises and one should resist the
temptation to perform complex techniques simply
to try them out and increase ones experience.
The unfortunate results of such exercises are all to
frequent.
3. In considering reconstruction of any defect,
particularly in multi-digit injuries, consideration must
be given to the overall outcome to hand function,
with most priority accorded the areas that are of
higher functional importance.
4. The patient must receive a good explanation of the
plan, the expected post-operative course and
required compliance along with the possibility of
failure or the need for secondary procedures. This
explanation must also include a fair assessment of
the surgical cost of such procedures, with detail of
the consequences of skin graft harvest, secondary
defects of ap harvest, etc.
5. If tissue, such as an irreversibly damaged digit, is to be
discarded, one should consider the opportunity to
harvest elements (such as skin, nail, cancellous bone
graft) for use in other injured digits.
6. Points of technique for the various methods must be
respected, since there is little room for error. These
reconstructions frequently involve the creation of
defects larger and more complex than those at
presentation. One must be reasonably sure of ones
ground in embarking on such procedures.
The future will, no doubt, produce innovative and ingenious approaches to the management of these potentially debilitating injuries. The frontiers which limit the
calibre of our reconstructions are mostly concerned
with the restoration of sensibility. A reliable and repro-

CURRENT ORTHOPAEDICS

ducible method of assessing the outcome of our repairs

continues to elude us.One would wish for progress in the
management of those perennial problems in the hand:
the neuroma, cold intolerance, scar contracture. Despite
huge advances in microsurgical techniques, the outcome
of nerve repair remains obstinately inversely proportional to the patients age. Advances in understanding of
nerve regeneration and methods of inuencing nerve recovery may one day transform our entire approach to
these common and challenging injuries.

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2. Foucher G, Marin-Braun F, Merle M, Michon J. Le doigt banque
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3. Tranquili-Leali E. Ricostruzione dellapice delle falangi ungueali
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