[The semi-occlusive dressing in treating Allen III and IV fingertip injuries as an alternative to local skin flaps]

Occlusive dressing versus local flap coverage for the treatment of fingertip amputations with exposed bone: a comparative study

We retrospectively reviewed the outcomes of 54 patients treated with occlusive dressings (OD) (27 patients) or local flap (LF) coverage (28 patients) for fingertip amputations with bone exposure. All patients healed completely within a mean of 5 weeks in the OD group and 3.5 weeks in the LF group. At a mean follow-up of 26 months (range 12-38), 2-point discrimination was significantly better in the OD group (4 mm) than the LF group (6 mm). Proximal interphalangeal joint (PIP) stiffness was more common in the LF group, affecting one-third of patients. A cost analysis showed that ODs were 6.5 times less expensive than LFs performed in the operating theatre. OD appears to be a reliable and more cost-effective alternative to LF for treating zone 2 and 3 fingertip amputations with exposed bone, with similar healing time, better tactile discrimination and a lower rate of PIP joint stiffness.Level of evidence: IV.

Secondary Intention Healing for Fingertip Amputations in a Tropical Climate

Background: Various studies have examined occlusive dressings in fingertip amputations and reported good outcomes. Occlusive dressing preserves appropriate pH, cell accumulation and moisture for healing, thereby limiting scar formation and deformity. To our knowledge, no study was performed in tropical Asia. This study aims to demonstrate the viability of healing fingertip amputations through secondary intention using an effective dressing technique, even in warm tropical climates. Methods: All patients who presented to our institution with fingertip amputations from 1 July 2020 to 31 July 2022 were analysed retrospectively. Seventeen patients (15 male, 2 female) of mean age 37.2 ± 9.4 years old with 18 injured digits were retrospectively analysed. Twelve (66.7%) were Allen Type III injuries, and one patient required distal phalangeal K-wire fixation. During the patient's final review, static 2-point discrimination, pulp sensation, fingertip contour and nail deformities alongside the last measured range of motion (ROM) of the injured finger was recorded. Treatment duration and days of leave taken were also summed and assessed. Results: Patients were dressed with semi-occlusive dressing for an average of 20.1 ± 6.83 days. The average total duration of dressing is 36.78 ± 18.88 days over an average of 7.18 ± 4.03 dressing visits. Mean duration of follow-up was 108 ± 63.46 days. Good outcome measures in sensation, pulp contour, nail deformity and ROM similar to existing literature were reported. Conclusions: Occlusive dressing remains a viable and feasible treatment option for fingertip amputation even in a tropical climate. While this simple treatment method may require more effort from patient, wound healing was attained after 36.8 ± 18.9 days of dressing. Level of Evidence: Level IV (Therapeutic).

Semi-occlusive dressing versus surgery in fingertip injuries: A randomized controlled trial

OBJECTIVES

No gold-standard treatment has been established for the management of distal digital amputation in Ishikawa zones II and III. The objective of this study was to compare the results of management of fingertip amputation by semi-occlusive dressing versus surgery. The principal hypothesis was that a semi-occlusive dressing results in better recovery of sensory function than a digital flap.

METHODS

We conducted a prospective, randomized, multicenter study of 44 patients: 23 managed conservatively with semi-occlusive dressing, and 21 surgically with digital flap.

RESULTS

Mean follow-up was 12 months. Mean healing time was 4.9 weeks in the semi-occlusive dressing group and 3.6 weeks in the surgery group. There was no significant difference between groups for sensory recovery of fine touch (p = 0.198) or 2-point discrimination (p = 0.961). No infections were reported in either group. Hook-nail deformity was more frequent in the semi-occlusive dressing group, particularly in case of amputation in zone III.

CONCLUSIONS

Semi-occlusive dressing enabled satisfactory healing and sensitivity recovery without increasing the risk of infection. However, in zone III amputation, we advocate surgical treatment with a digital flap, due to poor trophicity and the frequency of hook-nail deformity seen with conservative management.

LEVEL OF EVIDENCE

II.

The reconstruction of fingertip injury by mini hallux toenail flap pedicled with the hallux transverse artery and toe pulp vein transplantation technique based on the equivalent design theory

INTRODUCTION

How to reconstruct the damaged fingertip is a clinical problem. Our team propose the theory of equivalent design and use the mini toenail flap pedicled with the hallux transverse artery and toe pulp vein transplantation technique to reconstruct Allen's type II fingertip injury. Thus, we perform the retrospective study to evaluate the effects of this technique on fingertip injury.

MATERIALS AND METHODS

A retrospective analysis was performed on 56 patients admitted to our hospital from January 2015 to January 2020 who used equivalently designed miniature hallux toenail flaps for the plastic repair of fingertip damage. We recorded the size of the miniature hallux toenail flap, operation time, intraoperative blood loss, and complications and calculated the survival rate of the transplanted miniature hallux toenail flap. During routine follow-up after surgery, we recorded nail growth time and observed finger appearance. At the last time of follow-up, we recorded Semmes-Weinstein evaluating tactile sensation and Two-point discrimination testing (TPD). The efficacy was evaluated by Zook score evaluation.

RESULTS

The size of the mini hallux toenail flap was 0.71 cm × 1.22 cm to 0.88 cm × 1.71 cm. The operation time was (3.54 ± 0.58) hours, the intraoperative blood loss was (20.66 ± 4.87) ml, and the survival rate of mini hallux toenail flaps was 100%. The postoperative follow-up time was (30.82 ± 11.21) months, and the total nail growth time was (9.68 ± 2.11) months. The average tactile sensation evaluated by the Semmes-Weinstein test was (0.32 ± 0.14) g, and the average TPD was (7.33 ± 1.02) mm. According to Zook score, the curative effect of fifty-six cases were all excellent or good with 100% excellent and good rate, and all patients had beautiful appearances and good function of damaged fingertips.

CONCLUSIONS

Based on the equivalent design theory, the mini hallux toenail flap pedicled with the hallux transverse artery and toe pulp vein transplantation technique is an effective method to reconstruct Allen's type II fingertip injury with a beautiful appearance and good function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Clinical effects of resurfacing fingertip amputations in long fingers using homodigital dorsal neurofascial broaden pedicle island flaps

The use of homodigital dorsal neurofascial broaden pedicle island flaps (HDNBPIF) to treat fingertip amputations is an ongoing research topic. Here, we evaluated the clinical effects of resurfacing fingertip amputations in long fingers using HDNBPIF. Seventeen patients with 18 long fingers were treated with HDNBPIF from December 2018 to May 2021. Total active motion (TAM) scores, Semmes Weinstein monofilament (SWM) test, static 2PD test, visual analogue scale (VAS), Vancouver scar scales (VSS), and quick DASH scores were evaluated at 12-25 months postoperation. The aesthetic satisfaction of the patients was estimated subjectively using a 5-point Likert scale. The mean defect size was 1.11 × 1.13 cm and mean flap size was 1.32 × 1.32 cm. All flaps survived and the mean TAM of injured fingers was 255.6° (Contralateral side: 268.4°, p < 0.05). Mean SWM score in the flap was 3.90 g, and 3.22 g in the donor zone. Mean static 2PD discrimination in the flap was 5.61 mm and 4.33 mm in the donor zone. Mean quick Dash scores were 5.81 whereas Mean VAS score in the flap was 0.7 and 0.2 in the donor site. Vancouver scar scales at the donor and recipient sites ranged from 0 to 2. At the end of the follow-up, all patients reported good aesthetic appearance and curative effects. These results show that HDNBPIF is a promising strategy that achieves good curative effects and recovery of fingertip functions.Type of Study and Level of Evidence: Therapeutic IV.

Semi-occlusive dressing therapy versus surgical treatment in fingertip amputation injuries: a clinical study

Objectives

Treatment of fingertip amputations is subject of controversial debates. Recently, semi-occlusive dressings have increased in popularity in these injuries.

Aims

To compare clinical outcomes of conservative semi-occlusive dressing therapy versus surgical treatment of fingertip amputations.

Methods

Eighty-four patients with fingertip amputations were re-examined clinically after a mean follow-up of 28.1 months (range 9.6–46.2). Sixty-six patients (79%) were treated with semi-occlusive dressings (group 1) and 18 (21%) underwent surgery (group 2). Range of motion, grip strength, and two-point discrimination were measured at the final follow-up. Furthermore, VAS score, Quick-DASH score, subjective aesthetic outcome and loss of working days were obtained.

Results

Group 1 demonstrated healing in all 66 patients (100%) while in Group 2 5 out of 18 patients (28%) failed to achieve healing after a mean of 17 days (range 2–38) due to graft necrosis. Group 1 showed significantly lower VAS scores and significantly lower loss of two-point discrimination compared to Group 2. Work absence was significantly shorter in Group 1 versus Group 2. Trophic changes in finger (46%) and nail (30%) were significantly lower in Group 1 compared to Group 2 (44% and 70%, respectively). Disturbance during daily business activities (14%) and cold sensitivity (23%) were significantly lower in Group 1 compared to Group 2 (86% and 77%, respectively).

Conclusions

Semi-occlusive dressing therapy for fingertip amputations demonstrated excellent healing rates. Compared to surgical treatment, it resulted in significantly better clinical outcomes, lower complication rates and significantly higher reported satisfaction rates. Therefore, semi-occlusive dressing for fingertip injuries is a very successful procedure and shall be preferred over surgical treatment in most cases.

Level of evidence

III therapeutic.

IV3000 semi-occlusive dressing use in simple and complex fingertip injuries: efficacy and affordability

Objective:

This study aimed to explore the efficacy of the IV3000 semi-occlusive, transparent adhesive film dressing in the non-surgical management of simple as well as more complex fingertip injuries.

Method:

In this qualitative study, patients with fingertip injuries were prospectively recruited and treated conservatively with the dressing between 2015 and 2017. Inclusion criteria included any fingertip injury with tissue loss and patient consent for non-surgical treatment consistent with the study protocol. Exclusion criteria included injuries needing surgical intervention for tendon injury or exposure, joint dislocations, distal phalangeal fractures requiring fixation, bone exposure, isolated nail bed lacerations and any patients eligible for surgical repair who did not wish to be managed conservatively.

Results:

A total of 64 patients took part in the study. The patients treated with the dressing were asked to rate functional outcome, of whom 40 (62.5%) patients reported the outcome as ‘excellent’, 19 (29.7%) as ‘satisfactory’, five (7.8%) as ‘indifferent’ and none (0%) as ‘unsatisfactory’. A reduced pulp volume at completion of healing was felt by 21 (32.8%) patients, but all patients were ‘satisfied’ with the aesthetic appearance of their fingertips at final clinical review. Average healing time was 4.5 weeks across the group, with the average time for return to work being just under one week. We estimate a 60% reduction in cost with the conservative versus the surgical management option.

Conclusion:

This study showed that, for participants, the IV3000 dressing was an affordable and effective option for the conservative treatment of simple fingertip injuries and in the management of more complex fingertip injuries.

Nail Regeneration of an Allen III Fingertip Amputation After a Dog Bite Using the Semi-occlusive Dressing Technique: A Case Report and Literature Review

There is ongoing controversy regarding the best treatment of fingertip amputations, conservative treatment with secondary healing or surgical intervention. Healing by secondary intention has been proven to offer satisfactory recovery and function. More extensive wounds are treated surgically. However, even in Allen III and IV amputations, there is a lack of evidence to support enhanced healing and function of fingertips after surgical treatment compared to conservative management. Regarding fingertip amputations after animal bites, thorough debridement is the preferred treatment due to various micro-organisms, while there is no consensus about the primary closure of the wound.

Inclusion cri­teria are complete amputations even with bone involvement at all levels. Exclusion criteria are skeletonized distal phalangeal bone, not surrounded by soft tissues, joint involvement and exposed tendon. It offers complete regeneration of the fingertip without signs of infection, even in animal bites wounds. There are few reports in the literature regarding the semi-occlusive dressing for treating fingertip amputations-only one report uses this technique after an animal bite in a two-year-old girl.

In this case report, an Allen III fingertip amputation caused by a dog bite in a 64-year-old female was managed successfully using the semi-occlusive dressing technique. At the final follow up three months after the injury, the aesthetic results were satisfactory. The fingertip with the nail complex was almost normal with no nail hook deformity. The pad skin regenerated with no signs of infection. The functional results were excellent, with no joint stiffness or disability. The sensibility was satisfactory with two-point discrimination of 4 mm, and there was no tenderness, cold intolerance, or neuroma. The patient was satisfied and able to participate in all daily activities. 

The semi-occlusive dressing technique is an alternative treatment option for Allen III fingertip amputations after animal bites. It promotes regenerative healing, and despite bacterial colonization, no infection has been reported.

Long-term outcome of a "short" anterograde homodigital neurovascular island flap with a simple or double V-Y plasty

INTRODUCTION

Anterograde homodigital neurovascular island flaps are very useful for reconstructing proximal fingertip amputations with exposed bone but have the disadvantage of bringing about proximal interphalangeal joint (PIPJ) stiffness. The addition of a single or double V-Y plasty increases mobility without having to extend the dissection beyond the PIPJ. The purpose of this study was to examine the long-term functional outcome of patients who received a "short" anterograde homodigital neurovascular island flap with a single or double V-Y plasty. Our primary hypothesis was that this flap did not induce PIPJ stiffness and our secondary hypothesis was that it preserved good fingertip sensation.

MATERIALS AND METHODS

This was a retrospective study of patients operated between August 2017 and February 2019. The inclusion criteria were the following: a fingertip amputation caused by either a crush or laceration injury with exposed bone, treated during the acute phase of the injury or for secondary necrosis (attempted replantation or subtotal amputation) and classified as type II oblique palmar, type III or type IV amputations according to the Allen classification system. The assessment criteria were: joint mobility, sensory evaluation with the two-point discrimination and Semmes-Weinstein monofilament tests, time to healing, postoperative complications, postoperative splinting, duration of work stoppage, perioperative smoking, cold intolerance, touch hypersensitivity, nail deformity and excluded finger.

RESULTS

Nine patients (mean age 53.9 years [32-67]) were operated, of which eight long fingers and one thumb. One procedure was complicated by skin flap necrosis. At the mean follow-up of 22.4 months [16-31], the mean mobility for the metacarpophalangeal joint (MCPJ), proximal interphalangeal joint and distal interphalangeal joint (DIPJ) were 92-0-0°, 97.8-1.5-0° and 60.3-6.8-0°, respectively. In comparison to the contralateral side, a significant difference was only detected in the DIPJs. The mean two-point discrimination in the proximal portion of the flaps were 7.1mm on the ulnar side (p<0.05) and 7.6mm on the radial side (p<0.01), while in the distal portion they were 7.3mm (p<0.01) and 7.8mm (p<0.01). The Semmes-Weinstein monofilament test also detected significantly reduced sensation.

CONCLUSION

The combination of a "short" anterograde homodigital neurovascular island flap with a single or double V-Y plasty seems to avoid PIPJ stiffening while preserving good fingertip sensation.

LEVEL OF EVIDENCE

IV; retrospective study.

Fingertip injuries managed by a thenar flap: Follow-up and long-term outcomes of 32 cases

While various techniques are used for the reconstruction of fingertip injuries, the main goals remain the same: preserve finger length, sensation, and function. The thenar flap is a well-described technique and simple procedure in fingertip amputations. This study aimed to evaluate the long-term functional and esthetic outcomes along with patient satisfaction of thenar flaps done for fingertip defects. Thenar flaps used in 32 patients operated between January 2010 and December 2016 were analyzed retrospectively to assess sensory recovery, range of motion, cold intolerance, pain relief, appearance, patient satisfaction, and QuickDASH score. All flaps survived, without adverse events. The flap was detached after 10-14 days (mean 12.5 days). The mean follow-up was 31 months (range, 20-45 months). According to Semmes-Weinstein monofilament test results, protective sensation was achieved in 25 patients (78%). The mean static 2-point discrimination was 6.1 mm. There were no functionally significant finger flexion contractures at the final follow-up. Complications such as pain, donor site morbidity and cold intolerance were not encountered. The thenar flap is an excellent technique for coverage of total or subtotal tissue loss of radial-side fingertips that is not accessible to local flaps. It provides good sensory function and appearance when fundamental technical principles (flap design, timing of division, and early mobilization) are respected.

Long-term outcome of fingertip reconstruction with the homodigital neurovascular island flap

INTRODUCTION

Fingertip injuries are frequent and several surgical strategies exist to reconstruct the amputated part and restore function and appearance. Yet, long-term results are rarely published. The purpose of this study was to examine the long-term clinical outcome of neurovascular island flaps for traumatic fingertip amputation of Allen type III/IV injuries.

MATERIALS AND METHODS

We retrospectively analysed a cohort of patients with traumatic fingertip amputation that underwent reconstruction with a neurovascular island flap from January 2003 to December 2014. No mandatory splinting was applied after surgery. 28 participants (29 fingers) were available for follow-up at mean 8 years after reconstruction. Activities of daily living were measured with the disabilities of the arm, shoulder and hand questionnaire. Grip strength and finger motion were assessed using a Jamar dynamometer and a goniometer. Two-point discrimination and Semmes-Weinstein monofilaments were used to evaluate sensory recovery.

RESULTS

No intraoperative complications occurred and all flaps survived. Mean flap size was 4.7 ± 0.6 cm². Active motion of the fingers was over 95% of the contralateral side at follow-up. Three patients showed mild extension lag of the proximal interphalangeal joint. The grip strength of the affected hand and of each of the affected fingers was over 70% of the contralateral side. In comparison to the contralateral side we did not detect any significant difference for the Semmes-Weinstein monofilament test, but two-point discrimination (5.1 ± 1.7 mm) was significantly impaired. According to the Lim classification 1 of 14 nails with hook nail deformity showed grade 3 breaking of the nail. The DASH score was 16.0. All patients returned to their original occupation and patient satisfaction with the procedure was high.

CONCLUSIONS

The risk for disabling flexion contracture seems to be small even without mandatory splinting. Neurovascular island flaps for fingertip amputation of Allen type III/IV injuries are a reliable tool in fingertip reconstruction in the long term.

Conservative treatment of fingertip injuries in children - first experiences with a novel silicone finger cap that enables woundfluid analysis

Introduction: Human fingertips are able to regenerate soft tissue and skin after amputation injuries with excellent cosmetic and functional results when treated with semiocclusive dressings. Despite bacterial colonizations, proceeding infections are not reported with this management. The underlying mechanisms for this form of regenerative healing as well as for the resilience to infections are not known. Due to the lack of mechanical protection, the leakage of maloderous woundfluid and the sometimes challenging application, conventional film dressings have their problems, especially in treating young children. We therefore treated selected patients with a novel silicone finger cap with an integrated wound fluid reservoir that enables atraumatic routine wound fluid aspiration.

Methods: We report on 34 patients in between 1 and 13 years with traumatic fingertip amputations primarily treated with occlusive dressings. 12 patients were treated with a novel silicone finger cap. We summarized clinical data for each patient. This included photographs and microbiological results from wound fluid analyses, whenever available.

Results: The results of both, conventional film dressing and silicone finger cap treatment, were excellent with no hypersensitivity and no restrictions in sensibility and motility. Even larger pulp defects were rearranged in a round shape and good soft tissue coverage of the distal phalanx was achieved. Nail deformities were not observed. We detected a wide spectrum of both aerobic and anaerobic bacteria in the wound fluids but infections were not observed. Epithelialization times did not differ significantly and no severe complications were seen in all primarily conservatively treated patients.

Conclusion: This study provides preliminary data demonstrating that the treatment with the silicone finger cap leads to excellent clinical results in wound healing. Interestingly, the wounds were colonized with a wide range of bacteria including species that may cause wound infections. However, we saw no proceeding inflammation and the regeneration was undisturbed. In the future, the efficacy of this new management should be evaluated in randomized, controlled clinical trials to confirm the results under standard conditions and get more insight into the role of the wound microbiome as well as other factors that may promote regeneration. The aspirable Reservoir of the finger cap will enable easy atraumatic sampling of wound fluids both for diagnostic and for research purposes as well as possibly allowing direct administration of pro-regenerative drugs in the future.

[Hands well - all's well : Prevention campaign of the Austrian General Accident Insurance Institution (AUVA) to reduce hand injuries]

Overall, 41% of all work-related accidents lead to a hand injury. In the younger generation, the incidence rate even rises to 50%. In Austria, these accidents result in approximately half a million sick leave days per annum, an average of 12.5 days per accident. In comparison, leisure-time hand injuries show a significantly higher accident rate: 60% of hand injuries occur during leisure time. Far fewer safety measures are taken and a lack of adequate training and a disregard for safety recommendations are observed.This large number of hand injuries led to the launch of a campaign in Austria in 2014-2015 called "Hände gut - Alles Gut", (Hands well - all's well). This campaign was aimed at reducing the costs, a sum of 309 million Euros, incurred solely from work-related hand accidents, by at least 5-10%.These exorbitantly high costs are not only due to severe hand trauma, most result from a multitude of slight and superficial wounds.