Xray of Fracture of Proximal Phalanx of Middle Finger

Following xray is of 34 years old male who had a injury to his right hand following a motor vehicle accident.

The xray shows fracture of proximal phalanx of middle finger

Fracture Proximal Phalanx

Fracture Proximal Phalanx of Middle Finger

The fracture was treated with closed reduction and kwire fixation under Carm image intensifier.

Dislocations of Distal Interphalangeal Joints of Hand

Distal interphalangeal joints of the hand have complex motion patterns that are different for each finger and designed to ensure conformity when the hand surrounds an object.

Dislocations of the distal interphalangeal joints can be closed or open.

Most of the dislocations are reducible by closed methods.Irreducible dislocations of the DIP joint occur due to

  • Volar plate entrapment
  • Flexor digitorum profundus is trapped behind a single condyle of middle phalanx
  • Middle phalanx is  buttonholed through the volar plate
  • Middle phalanx is buttonholed  through a rent in the FDP
  • The extensor tendon is displaced around the head of middle phalanx

[Read more...]

Xrays of Fracture of Base of First Metacarpal

Fracture of base of first metacarpal in 34 years old male.

Fracture of Base of First Metacarpal Bone

Fracture of Base of First Metacarpal Bone

Under local anesthesia, the fracture was reduced by closed reduction methods and and fixed by a Kwire.

Fracture Reduced and Fixed Visualized in Carm image intensifier

Fracture Reduced and Fixed Visualized in Carm image intensifier

At present time, the patient is in third week of followup and showing good improvement

Fractures of Distal Phalanx of The hand

Distal phalanx of the hand is terminal contact of the upper limb with surroundings and is at risk of injury with nearly every use of the hand.

Fracture Pattern

Fractures in the distal phalanx can be conceived of as occurring in three primary regions [Anatomy of the distal phalanx]

  • The tuft (63%)
  • The shaft (36%)
  • The base (18%)

Mechanism

Sudden axial load as in ball sports or crush injuries are mainly responsible for injuries to the distal phalanx. [Read more...]

Anatomy of The Nail Bed of Fingernails

The nail, an integral component of the digital tip serves to protect the fingertip, provides counterforce to tactile sensation  and carries thermoregulationion via glomus bodies in the nail bed and matrix.

Parts of The Nail

Nail Plate

The nail plate (corpus unguis) is the hard visible part of the nail.   The nail plate is composed of hard, keratinized, squamous cells that are loosely adherent to germinal matrix but strongly attached to the sterile matrix.

Matrix

Matrix is the tissue that a nail [nail plate] protects. It lies beneath the nail and contains nerves, lymph and blood vessels. The matrix is responsible for producing cells that become the nail plate. It has two parts strile and germinal.

Lunula

Lunula represents distal extent of the germinal matrix.

Hyponychium, Eponychium and Paronychium

The hyponychium is the epithelium located beneath the nail plate at the junction between the free edge of the nail and the skin of the fingertip.

The eponychium is the small band of epithelium that extends from the posterior nail wall onto the base of the nail.

Paronychium are the lateral nail folds on either side of nail plate.

 

Antatomy  of Nail

 

Blood Supply

The arterial blood supply to the perionychium originates from the terminal branches of the radial and ulnar proper palmar (volar) digital arteries.

 

Nail Abnormalities After Trauma

Nail bed injuries can lead to  a number of nail abnormalities. Commonly encountered nail deformities are nonadherence, split nails, linear ridging, crooked nails, and hooked nails.

Nonadherence

Nonadherence occurs when the nail does not adhere to the abnormal scar that has formed within the injured nail bed.

Nonadherance is the most common nail deformity after nailbed injury. It could be distal nonadherence or proximal one.

Distal nonadherance can cause problem of dirt being lodged underneath the nail. [Read more...]

Treatment of Nailbed Injuries

Treatment of nailbed injuries depend on the severity of the injury. A radiograph must be obtained to rule out an underlying fracture.

Grade I injuries

Grade I injuries are treated nonoperatively in most of the cases. If the injury is very painful, decompression or nail removal can be performed.

 Grade II, III, and IV Injuries

All grade II, II and IV  injuries require nail removal and repair of the nailbed.

After removal of the nail, debridement of the nailbed is done if required and nailbed is repaired using appropriate sututres.

A splint or kwire fixation may be required for distal phalanx fracture.

After repair, the  nail  is replaced as it serves as a template for the new growing nail and provides a biologic dressing.

The finger is protected and motion is restricted for 7-10 days.

Nail Bed Avuslion

Nail bed avulsions account for approximately 15% of all traumatic injuries to the nail. For treatment, the avulsed nail bed is sutured in an anatomic position. If the avulsed nail cannot be sutured back, a split thickness nail matrix graft can be used.

First Dorsal Metacarpal Artery Flap

The first metacarpal artery flap restores sensate skin to the volar thumb in a one-stage procedure without the need for microvascular repair.

The first dorsal metacarpal artery is superficial to the dorsal interosseous fascia.  Before making the incision, a Doppler scan may be used to identify the first dorsal metacarpal artery.

The flap can be used to cover thumb defects, either palmarly or dorsally, and can reach from the proximal portion of the thumb almost to its tip. [Read more...]

Neurovascular Island Flap For Thumb

Neurovascular island flap transfers the soft tissue of the border of a finger along with its arterial and nerve supply [Neurovascular bundle] to the thumb.

It is also known as Littler flap.

This provides a soft tissue to the thumb which is sensate though it sacrifices sensation in a finger from which it is transferred.

It can be performed as a primary or reconstructive procedure in thumb injuries.

The donor site of the flap is often the ulnar border of the long finger. Ulnar or radial aspect of the ring finger can also be used. [Read more...]

Moberg Advancement Flap

Moberg advancement flap consists of advancing the the volar skin with its subcutaneous tissues and neurovascular bundles distally into a thumb tip defect.

The unique anatomy of the thumb makes this flap more suitable for the thumb than the other digits.

There is a substantial risk of flexion deformity after this surgery and if it occurs in thumb, it causes little functional problem in thumb than if it occurs in others.

Moreover the thumb is less dependent on the volar blood supply than fingers and there is a risk of tip necrosis with this flap in fingers.

The flap is indicated in  volar oblique amputation of the thumb. [Read more...]