Use of modified tension band sutures for fingernail disruptions

A series of 66 patients, aged between 1 and 70 years, with 70 disruptive injuries to finger nails was reviewed. The injuries were treated by cleaning of the finger, evacuation of haematoma and anatomical replacement of the nail plate, or a substitute, which was secured with a modified dorsal tension band suture without formal repair of the nail bed. K-wire fixation of the distal phalanx was employed only in the event of displaced fracture of the distal phalanx, complete absence of the nail plate and laceration extending to the distal pulp. This simple method, which bypasses the injured and friable, but vital nail structures resulted in uncomplicated re-formation of the normal nail plate in all of the cases. Removal of the nail plate and formal repair of the nail bed is not necessary in any age group with finger nail disruptions.     

Arterialized venous toenail flaps for treating nail loss in the fingers

Ten arterialized venous toenail flaps with two venous pedicles, one of which was anastomosed to a digital artery and the other to a dorsal vein of the finger, were used in nine patients to reconstruct nail loss due to trauma. Four flaps were taken from the lateral part of the big toe and six flaps from the second toe. Four toenail flaps with pulp and three flaps with the distal half of distal phalanx were used. Nine flaps survived completely and one had partial necrosis. All showed excellent aesthetic and functional results except for one case with minimal deformity in growth of the nail. The mean operating time was 2 hours.     

Similarities between a conjoined nail and the palmar nail syndrome

The congenital palmar nail syndrome consists of a triad of palmar nail, absent finger flexion and abnormalities of the distal phalanx. There are two main theories about the pathogenesis of this syndrome: the ancestral reversion theory and the duplication theory. In this paper, similarities between a conjoined nail in conjoined twins and the palmar nail syndrome are described to support the duplication theory.     

Regeneration of nails with artificial dermis

Abstract We treated fingertips injured through the proximal half of the nail bed using artificial dermis in 22 patients from 2004 to 2009. We classified the injuries to the nail bed into three types according to where the wounds were. Type ? was localised to the nail bed with or without minor injury to the surrounding structure; type II was an avulsion and amputation of the fingertip including the nail bed, the finger pulp, and the distal phalanx at the level of the proximal nail bed; and type III was post-traumatic shortening of the nail, in which the pulp and distal phalanx were intact. Regeneration and elongation of the nail was achieved in every patient by applying artificial dermis. All patients were satisfied with the results.     

Regeneration of nails with artificial dermis

Abstract

We treated fingertips injured through the proximal half of the nail bed using artificial dermis in 22 patients from 2004 to 2009. We classified the injuries to the nail bed into three types according to where the wounds were. Type ? was localised to the nail bed with or without minor injury to the surrounding structure; type II was an avulsion and amputation of the fingertip including the nail bed, the finger pulp, and the distal phalanx at the level of the proximal nail bed; and type III was post-traumatic shortening of the nail, in which the pulp and distal phalanx were intact. Regeneration and elongation of the nail was achieved in every patient by applying artificial dermis. All patients were satisfied with the results.     

静脉移植和吻合掌侧静脉在不同平面末节断指再植中的应用

目的 探讨不同平面末节断指的再植方法.方法 2004-2007年,对63例71指末节断指,按损伤部位分为4区,采用静脉移植和吻合掌侧静脉的方法进行再植.结果 术后71指存活70指.随访时间为3个月至3年,再植手指饱满,手指长度正常,指甲外观满意.再植指两点分辨觉平均为6.5 mm,除Ⅳ区关节融合者外,其余拇指指间关节与远侧指问关节活动度平均为69°.结论 对末节断指的处理,为保留手指长度和指甲,血管移植修复是必要的,尤其是Ⅱ区和Ⅲ区,同时行掌侧静脉吻合对末节再植的成功至关重要.     

Reconstruction of Composite Soft Tissue Defect in the Distal Finger Using Partial Toenail Flap Transfer

Objective

Composite tissue loss involving the distal finger pulp and the nail is a common but challenging finger injury to restore. This study introduces a reconstruction procedure for a distal finger pulp and nail defect using a partial toenail flap transfer.

Methods

Twenty digits, including 16 thumbs, two index fingers, and two middle fingers, with composite soft tissue defects were treated with a partial toenail flap transfer from October 2015 to January 2020. Shortening revision of the great toe phalanx, a V-Y advancement flap of the toe pulp, and a local pedicle flap from a second toe transfer were used to cover the donor sites, and no skin grafts were required. Functionality was evaluated using the validated Spanish version of the Quick-DASH scale. The aesthetics of both the reconstructed and donor sites were evaluated using the Vancouver Scar Scale (VSS). The static two-point discrimination (2-PD) of the finger pulp was used as a measure of tactile agnosia.

Results

All donor site wounds healed well. The average follow-up time was 23.6 months (6–39 months). The mean Quick-DASH functional score was 7.1. The VSS scores were 4.02 ± 0.29 and 4.00 ± 0.38 for the reconstructed and donor sites, respectively. The static 2-PD of finger pulp was 4.5 ± 0.76 mm. The patients were satisfied with finger motion, sensory function, and aesthetic contour.

Conclusions

Partial toenail flap transfer is the recommended treatment to regain motion, sensation, function, and a satisfactory aesthetic appearance when considering repairing a composite soft tissue distal finger defect with accompanying loss of the perionychium, particularly in the thumb, index finger, or middle finger.     

手指末节套脱伴甲床缺损的一期修复

目的 探讨应用携带附加筋膜瓣的指动脉岛状皮瓣联合断层甲床移植一期修复手指末节套脱伤的方法及疗效.方法 2005年6月至2008年10月,应用三种形式的携带附加筋膜瓣的指动脉岛状皮瓣联合断层甲床移植修复手指末节套脱伤9例,其中采用同指近节逆行岛状皮瓣6例,邻指中节顺行岛状皮瓣2例,结扎指总动脉邻指逆行岛状皮瓣1例.甲床移植来源为(母)趾7例,第二趾1例,撕脱甲床回植1例.结果 术后皮瓣及移植甲床全部存活,随访时间为3个月至2年,重建指腹外形饱满,两点分辨觉为6～12mm.3例新生指甲被覆完全,外形光滑、平整;2例新生指甲被覆超过4/5;3例超过1/2,与甲床贴附紧密;1例仅长出残留指甲.远指间关节活动度为30.～60°,供趾趾甲生长良好,行走功能正常.结论 携带附加筋膜瓣的指动脉岛状皮瓣联合断层甲床移植是修复手指末节套脱伤的一种可行方法.     

Epidermoid cyst of the phalanx of the finger caused by nail biting

Abstract

Intraosseous epidermoid inclusion cysts of the phalanx of the finger are rare, and are regarded as reactive or post-traumatic pseudotumours. We describe a case of an epidermoid cyst in the distal phalanx of the fifth finger caused by chronic nail biting, which was successfully excised.     

Biomechanical performance of short and long cephalomedullary nail constructs for stabilizing different levels of subtrochanteric fracture

IntroductionThe aim of this study was to assess biomechanical performance of short and long Cephalomedullary nail constructs consisting of different number of distal screw for stabilizing different levels of subtrochanteric fracture.Materials and methodsThe femur obtained from computed tomography scanner was used to create a transverse fracture at 15 mm (level A), 35 mm (level B), and 55 mm (level C) below the lesser trochanter. Short and long Cephalomedullary nails were virtually inserted to the fractured femur. Four-node tetrahedral element was used to build up finite element (FE) models for biomechanical analysis. The analysis focused on post-operative stage of partial weight-bearing.ResultsStress on the implant localized at the surface between lag screw/nail and distal screw/nail. Short Cephalomedullary nail exhibited higher stress than long Cephalomedullary nail. The stress in short Cephalomedullary nail could be reduced by using two distal screws fixation and the fracture at level A produced less stress than that of level B and C. Either short or long nail with two distal screws is sufficient to withstand the stress magnitude produced from the physiologic load. When single dynamic distal screw was used, stress on implant, elastic strain at fracture gap, and bone stress reached the high values. Elastic strain of the fracture gap at level C were less than that of level A and B, but no statistically significant difference. There was no proximal cancellous bone damage observed from the FE analysis.ConclusionsLong Cephalomedullary nail with at least two distal locking screws remains a proper implant for subtrochanteric fracture fixation in overall locations. However, short Cephalomedullary nail with two distal screws may be a candidate for a high subtrochanteric fracture. Single dynamic screw insertion is strongly not recommended with either short or long nail regarding implant failure.     

Transferts osseux vasculaires libres (TOVL) « en bout de chaîne »

The vascularized bone proved its capacity to be healed, without resorption even in sclerotic or infected tissue. Reconstruction of the distal part of the finger is often difficult for a pedicle transplant and a conventional bone transplant disappears. So the free vascularized bone transfer (FVBT) is indicated in distal post-traumatic finger amputations. According to the loss of substance to be reconstructed, the vascularised bone is harvested with some pulp, the nail complex or the cartilage of growth for a child. We report our experience of the technique of wrap around modified, of partial transfers of the second toe and the technique of reconstruction of claw nail deformity. The vascularised transfer of the cartilage of growth at the child is essential to allow the growth of the transferred phalanx. The indications are rare however the children, the musicians or the patients who require fine pinch can benefit from this type of sophisticated reconstructive microsurgery.     

Treatment of post-traumatic nail bed deformities with split-thickness nail bed grafts

INTRODUCTION: Split-thickness nail bed graft have been proposed for treatment of post-traumatic nail bed dystrophies. Only three papers reported good results in 60 to 90% of cases. We report our experience. MATERIAL AND METHODS: We reviewed 18 cases of split-thickness nail bed grafts from operative and consultation files and photographs. Evaluation was made using criteria as the nail plate shape, its adhesion on the nail bed, patient satisfaction and possible sequelae on the donor finger. RESULTANTS: Thirteen patients have been reviewed with a sufficient follow-up to assess the results. In 13 cases, the graft was taken from the hallux. The nail-bed graft was used for hallux reconstruction two times, the thumb six times, index six times, middle and ring finger one each, and the little finger two times. In every patient the graft was molded using either the patient nail or the nail plate from the donor finger. Clinical results were excellent in five cases, good in three and poor in five cases. Five failures were due to wrong indications in three cases in which matrix problem has been underestimated, and infectious failures in two cases. Fifteen per cent of our patients had some sequelae on the donor finger.     

应用第二套供血系统的全指甲再造术

目的探讨对手指指甲缺损或畸形进行精细重建的技术。方法对2003年12月-2004年6月在我院应用显微外科技术治疗的9例指甲（13指）缺损患者进行回顾性分析。所有患者均利用第二套供血系统以携带最小量组织进行切取包括趾甲、甲床、甲下皮、甲周膜在内的复合组织及其营养动脉、静脉和神经，与受区进行趾-指动脉、静脉、神经的吻合，完成单一全趾甲复合组织移植再造指甲。结果所有再造指甲均顺利成活，外形十分满意，接近原手指指甲的效果，供区的外观和功能无明显影响。结论应用第二套供血系统的全指甲单位再造术，可获得理想的治疗效果。     

手指指甲缺损的单全趾甲复合组织移植再造术

目的对手指指甲缺损或畸形进行重建，再造理想的指甲。方法以携带最小量组织进行切取包括趾甲、甲下皮、甲周膜在内的复合组织及其营养动脉、静脉和神经，与受区进行趾-指动脉、静脉、神经的吻合，完成单一全趾甲复合组织移植再造指甲。结果再造9例13指，术后均顺利成活，外形满意，接近原手指指甲的效果，供区的外观和功能无明显影响。结论应用显微外科技术，可使手指甲再造等手外科手术做的更精细，治疗效果更理想。     

Recommendation of use of checklists in tibial intramedullary nail removal: Retrospective study of mechanical complications related to nail removal

BackgroundThe removal of implants such as intramedullary nails is one of the most common operations in orthopedic surgery. The indications for orthopedic implants removal will always remain a subject of conversation and hardly supported by literature. The aim of this study to report injuries of treatment in tibial nail removal and to determine if there are fracture characteristics, patient demographics, or surgical details that may predict a complication.MethodsThis is a retrospective seven-year (2010–2016) study including a total of 389 tibial intramedullary nail removals at the Helsinki University Hospital’s orthopedic unit. Patients with tibial fracture and removal of intramedullary nail were identified from the hospital discharge register and analyzed.ResultsA total of 21 (5,4%) nail removal related mechanical complications (iatrogenic fractures, nerve injuries, failures to remove the nail) were noted. The most common complication was iatrogenic fracture (n = 15, 3,8%). In 6/15 cases the fracture was caused by broken interlocking screws, In 5/15 cases the iatrogenic fracture was caused accidentally by extracting the nail without prior removal of all distal interlocking screws. In one case, new condensed bone had formed around the nail’s distal end and case the forced nail extraction caused a re-fracture in both tibia and fibula.ConclusionNail removal can be a challenging operation which does not always receive the necessary preoperative planning or operative expertise. Iatrogenic fractures were most often caused by inadequate preoperative planning or assuming that a broken interlocking screw tilts during the extraction. We suggest the use of checklists in preoperative planning to avoid fractures caused by broken or undetected interlocking screws.     

Imaging of tumors of the nail unit

In case of suspicion of a deep mass beneath the nail plate, radiographs remain necessary to assess the distal phalanx and the distal interphalangeal joint. Ultrasonography may be helpful to depict a cystic or a vascular component of a tumor. Computed tomography is only indicated to accurately assess tiny abnormalities of the cortex of the distal phalanx. MR imaging offers a whole imaging of the soft parts of the nail unit and the underlying bone.     

Microvascular nail transfer

A composite of nail and its skin appendages can be transferred for the foot to the hand by microvascular anastomosis. For technical reasons, the most suitable donor nail is from the big toe, and this most closely approximates the thumb nail. A finite portion of hemipulp must be included with the transfer to ensure adequate vascularization. Nail size can be reduced by resection of the edges of the germinal matrix so as to match the donor defects. For finger nail reconstruction, it is usually more practical to transfer the whole of the tip of the second or third toe to replace the whole of the tip of the finger. The indications of nail reconstruction by this technique are relatively rare and are predominantly cosmetic.     

Free vascularized bone transfer en bout de chaîne

The vascularized bone proved its capacity to be healed, without resorption even in sclerotic or infected tissue. Reconstruction of the distal part of the finger is often difficult for a pedicle transplant and a conventional bone transplant disappears. So the free vascularized bone transfer (FVBT) is indicated in distal post-traumatic finger amputations. According to the loss of substance to be reconstructed, the vascularised bone is harvested with some pulp, the nail complex or the cartilage of growth for a child. We report our experience of the technique of wrap around modified, of partial transfers of the second toe and the technique of reconstruction of claw nail deformity. The vascularised transfer of the cartilage of growth at the child is essential to allow the growth of the transferred phalanx. The indications are rare, however the children, the musicians or the patients who require fine pinch can benefit from this type of sophisticated reconstructive microsurgery.     

Homodigital antegrade-flow neurovascular pedicle flaps for sensate reconstruction of fingertip amputation injuries

Fingertip amputations through the distal 50% of the nail matrix usually create a finger that is best served by maintaining length. When the amputation is more proximal than this, revision with ablation of the small residual nail unit may provide greater overall patient satisfaction. When amputations in the distal 50% of the nail matrix are transverse or short oblique in orientation, a flap of some kind is needed to restore the contact surface of the pulp. Many alternative reconstructive strategies are possible but have inherent limitations that detract from the quality of the final result. Inadequate padding, lack of sensibility, excessive tension, hook nail deformity, poor durability, and donor site morbidity are but some of the considerations. Although not a panacea for all distal fingertip amputations, the antegrade-flow homodigital neurovascular pedicle flap offers a good ratio of advantages to disadvantages. As with all flaps, knowledge and execution of the details largely determine the outcome.