Orthopedic Care and Consultation
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 of Middle Finger
The fracture was treated with closed reduction and kwire fixation under Carm image intensifier.
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
Fracture of base of first metacarpal in 34 years old male.
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
At present time, the patient is in third week of followup and showing good improvement
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]
Mechanism
Sudden axial load as in ball sports or crush injuries are mainly responsible for injuries to the distal phalanx. [Read more...]
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.
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 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 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.
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 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...]
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