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Fingertip Amputation

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101. Nail Surgery (Overview)

Onumah, MD; Chief Editor: William D James, MD Share Email Print Feedback Close Sections Sections Nail Surgery Overview Background The nail complex is the structural and functional unit of the nail. The nail consists of the plate; bed; matrix; proximal, lateral, and distal grooves; proximal and lateral folds; and hyponychium (see the image below). [ , , ] Aside from being aesthetically appealing, the healthy nail unit has the important function of protecting the distal phalanges, fingertips (...) the nail plate. [ , , ] Most commonly, the tumors are localized to the hand with involvement of the fingertips and the subungual region. Ultrasonography can be used to identify and locate the tumors. The onset of intense pulsating pain with the slightest pressure or with exposure to cold temperatures is pathognomonic for subungual glomus tumors. Microscopically, all the components in a glomus body are present in this tumor; the components are an afferent arteriole, an efferent venule, glomus cells

2014 eMedicine.com

102. Nail Surgery (Follow-up)

flap formed from amputation of the distal half of the terminal phalanx is sutured dorsally over the defect created from the excision of the nail bed and the nail matrix for primary wound closure. [ ] Radical matricectomy has a success rate of almost 100%, with low postoperative morbidity, despite the poor cosmetic and functional outcome. [ ] Soft tissue resection for ingrown nails is performed in cases of lateral nail wall hypertrophy. This procedure spares the nail matrix and the nail plate, which

2014 eMedicine.com

103. Hand, Nerve Injury Repair

Abu Ibn Sina in Persia during the 10th century, and Ferrara in Italy in the 17th century. [ , , , , ] Despite this early record of physicians attempting to classify and treat nerve injuries, the common belief prior to the 19th century was that nerves did not regenerate. As a result, any kind of major nerve injury was treated nonsurgically or with amputation. During the 19th century, the development of improved microscopic devices, along with enhanced staining techniques, allowed a more detailed (...) the index finger, thumb, and proximal palm near the thenar eminence by way of the palmar cutaneous branch. The ulnar nerve supplies the ulnar side of the hand and little finger. It also supplies the dorsal ulnar region of hand via the dorsal cutaneous branch of the ulnar nerve. The digital nerves lie adjacent to the distal interphalangeal flexion crease and supply the adjacent areas, but not the fingertips. Adjuvant findings that can help with localizing innervation deficits are the presence of dry

2014 eMedicine Surgery

104. Hand, Finger Nail and Tip Injuries

like or are contraindications to crossfinger and thenar flaps because of the risk for resultant joint stiffness. The mechanism of injury can influence availability of certain local flaps. A literature review by Sindhu et al indicated that in the United States, up to 90% of fingertip amputations are not treated with replantation, while in Asian countries, as a result of moral values and the importance of body integrity, most patients with fingertip amputations undergo replantation. [ ] Occupation (...) to regenerate soft tissues. The complications potentially encountered with the open technique include loss of volume and pulp. [ ] Primary Closure and Revision Amputation Many fingertip injuries can be closed primarily or by recruiting adjacent soft tissues. Viability of the remaining soft tissues must be ascertained before application of a tourniquet. Occasionally, the fillet flap principle can be applied in reconstructing these wounds. Occasionally, bone shortening or revision amputation is required

2014 eMedicine Surgery

105. High-Pressure Injection Injuries (Diagnosis)

that HPI injuries to the hand are relatively common, given the widespread use of pressure machinery. Previous Next: Prognosis HPI injuries often manifest as innocuous lesions on the fingertip of a patient's nondominant hand. Depending on the substance involved, these injuries may follow a benign clinical course (for air and clean water) or may be deceptively destructive and lead to soft-tissue necrosis and amputation (for grease and paint). Proper triage and management of HPI injuries of the hand (...) , leading to high amputation rates. [ , ] Grease has been shown to be associated with oleogranulomata formation (a reaction to foreign bodies), fistula formation, fibrosis, and poor functional outcomes. [ , , ] Joint contractures and ankylosis are also seen. [ ] Previous Next: Etiology Common substances involved in HPI injuries include the following [ , , ] : Grease (accounting for 57% of injuries, at pressures of up to 5000-10,000 psi) Paint (up to 5000 psi; see the images below) Diesel fuel

2014 eMedicine Surgery

106. Hand Infections

, epitrochlear and/or axillary lymphadenopathy may be present. Beta-hemolytic streptococci and S aureus are the usual pathogens. Felon A is an infection of the soft tissues at the volar pad of the terminal phalanx. [ ] The soft tissue of the fingertips is divided into multiple compartments by vertical fibrous septa extending from the dermis to the distal phalanx. Infections in this area thus mimic a compartment-like syndrome. A hot, red digital pulp implies the presence of pus and should be drained even (...) of irrigation and debridement procedures, patient comorbidities, and postoperative infection following nonjoint surgery. A higher risk for arthrodesis and amputation was noted in subjects who had more than 3 irrigation and debridement procedures. [ ] Osteomyelitis Like septic arthritis, of the bones of the hand can result from local extension of other hand infections, or it may be caused by hematogenous spread from a distant site. Most occurrences result from local extension. Staphylococci and streptococci

2014 eMedicine Surgery

107. Hand, Congenital Hand Deformities

below: Most commonly, radial hypoplasia, brachysyndactyly, or brachydactyly Type VI - Constriction band syndromes, as follows: See the list below: Occurs with or without distal lymphedema; may involve amputation at any level Type VII - Generalized anomalies and syndromes This classification system is imperfect (eg, atypical cleft hands are difficult to classify, falling into 1 of 3 possible groups), and the future undoubtedly holds a classification system based on improved knowledge of the molecular (...) ; the hands show symmetrical complex syndactyly. Dysplasia of the shoulder and elbow joint are also common. The hand deformity fits into 3 general patterns, as outlined in Table 5 below. [ ] Table 5. Classification of Apert Hand Deformity Classification 1st Web Space Central Mass 4th Web Space Type I: Spade hand Incomplete simple syndactyly Digital mass flat to palmar plane Incomplete simple syndactyly Type II: Mitten or spoon hand Complete simple syndactyly Digital mass curved due to fingertip fusion

2014 eMedicine Surgery

108. Nerve Entrapment Syndromes (Diagnosis)

: SYSTEMATIC REVIEW. Acta Ortop Bras . 2017 Jan-Feb. 25 (1):52-54. . Clavert P, Thomazeau H. Peri-articular suprascapular neuropathy. Orthop Traumatol Surg Res . 2014 Dec. 100 (8 Suppl):S409-11. . Lanz U. Anatomical variations of the median nerve in the carpal tunnel. J Hand Surg Am . 1977 Jan. 2(1):44-53. . Wilson KE, Tat J, Keir PJ. Effects of Wrist Posture and Fingertip Force on Median Nerve Blood Flow Velocity. Biomed Res Int . 2017. 2017:7156489. . Ball C, Pearse M, Kennedy D, Hall A, Nanchahal J (...) EVIDENCE-BASED CLINICAL PRACTICE GUIDELINE. American Academy of Orthopaedic Surgeons. 2016 feb 29; Accessed: September 21, 2017. Moriarty JM, Bandyk DF, Broderick DF, Cornelius RS, Dill KE, Francois CJ, et al. ACR Appropriateness Criteria Imaging in the Diagnosis of Thoracic Outlet Syndrome. J Am Coll Radiol . 2015 May. 12 (5):438-43. . . Dellon AL. Neurosurgical prevention of ulceration and amputation by decompression of lower extremity peripheral nerves in diabetic neuropathy: update 2006. Acta

2014 eMedicine Surgery

109. Nail Pathology (Diagnosis)

of mind" technique. The parents should be informed that the composite tip graft either survives or dies with this technique. Convert to a full-thickness skin graft to treat the composite fingertip amputation in adults and in children older than 10 years. The tissue is defatted to the level of the dermis, and the nail bed is preserved. The distal phalanx is shortened just below the remaining pulp soft tissue, and the full-thickness graft is applied and held with a stent dressing. The tip pulp (...) obtained vascularity. Again, the judicious use of sterile matrix grafts or germinal matrix grafts offers the best reconstructive results. Hook-nail deformity A hook-nail deformity is usually the result of a fingertip amputation, with partial or complete loss of the supporting tuft of the distal phalanx and a loss of the distal nail bed and fingertip soft tissue. The regenerating nail plate follows the contour of the repaired fingertip amputation, angling in a dorsal to volar direction. Amputated

2014 eMedicine Surgery

110. Arteriovenous Fistulas (Overview)

is a term reserved for a singular communication between an artery and a vein that usually has an acquired etiology. The first recorded case of an arteriovenous malformation (AVM) was in the late 16th century. In 1757, Hunter described an AVF as an abnormal communication between an artery and a vein. Krause in 1862 used injection studies of an amputated specimen to characterize the abnormal vasculature. In 1875, Nicoladoni described the reflex slowing of the pulse following occlusion of an artery (...) , Szajner M. Endovascular Treatment of Renal Arteriovenous Fistula with N-Butyl Cyanoacrylate (NBCA). Pol J Radiol . 2017. 82:304-306. . . Media Gallery Buttock port-wine stain. Lower extremity venous malformation. Upper extremity arteriovenous malformation (AVM). Hypertrophied subclavian artery resulting from low-resistance high-volume flow through an upper extremity arteriovenous malformation (AVM). Hand angiogram demonstrating arteriovenous connections. Note the steal of blood from the fingertips

2014 eMedicine Surgery

111. High-Pressure Injection Injuries (Overview)

that HPI injuries to the hand are relatively common, given the widespread use of pressure machinery. Previous Next: Prognosis HPI injuries often manifest as innocuous lesions on the fingertip of a patient's nondominant hand. Depending on the substance involved, these injuries may follow a benign clinical course (for air and clean water) or may be deceptively destructive and lead to soft-tissue necrosis and amputation (for grease and paint). Proper triage and management of HPI injuries of the hand (...) , leading to high amputation rates. [ , ] Grease has been shown to be associated with oleogranulomata formation (a reaction to foreign bodies), fistula formation, fibrosis, and poor functional outcomes. [ , , ] Joint contractures and ankylosis are also seen. [ ] Previous Next: Etiology Common substances involved in HPI injuries include the following [ , , ] : Grease (accounting for 57% of injuries, at pressures of up to 5000-10,000 psi) Paint (up to 5000 psi; see the images below) Diesel fuel

2014 eMedicine Surgery

112. Replantation (Diagnosis)

: L Andrew Koman, MD; Chief Editor: Harris Gellman, MD Share Email Print Feedback Close Sections Sections Replantation Overview Background Replantation of completely amputated digits has been a medical reality since 1968, when Komatsu and Tamai first reported successful replantation of a completely amputated thumb. [ ] Amputation of digits is common. Approximately 100,000 occur per year in the United States. Of those, an estimated 30% are suitable for replantation. The exact number (...) of replantations performed yearly is unknown. However, the number appears to be decreasing, secondary to more rigid selection criteria, improved workplace safety procedures, and better-designed protection devices on power tools. An image depicting digital amputation can be seen below. Complete amputation of two digits. Next: History of the Procedure Carrel performed experimental replantation of a canine hind limb in 1906. [ ] Malt successfully replanted a completely amputated arm in 1964, [ ] and Meredith

2014 eMedicine Surgery

113. Arteriovenous Fistulas (Diagnosis)

is a term reserved for a singular communication between an artery and a vein that usually has an acquired etiology. The first recorded case of an arteriovenous malformation (AVM) was in the late 16th century. In 1757, Hunter described an AVF as an abnormal communication between an artery and a vein. Krause in 1862 used injection studies of an amputated specimen to characterize the abnormal vasculature. In 1875, Nicoladoni described the reflex slowing of the pulse following occlusion of an artery (...) , Szajner M. Endovascular Treatment of Renal Arteriovenous Fistula with N-Butyl Cyanoacrylate (NBCA). Pol J Radiol . 2017. 82:304-306. . . Media Gallery Buttock port-wine stain. Lower extremity venous malformation. Upper extremity arteriovenous malformation (AVM). Hypertrophied subclavian artery resulting from low-resistance high-volume flow through an upper extremity arteriovenous malformation (AVM). Hand angiogram demonstrating arteriovenous connections. Note the steal of blood from the fingertips

2014 eMedicine Surgery

114. CREST Syndrome (Follow-up)

Surgical excision of localized painful large deposits can relieve symptoms; recurrence is rare. Saddic et al report a case of painful fingertip calcinosis treated with surgical debridement. [ ] If calcinosis is diffuse, recurrence is more common. Overzealous debridement to remove all calcinosis is apt to compromise digital viability and should be avoided. [ ] Successful palliation and significant remission of calcinosis using a carbon dioxide laser has been shown in 2 case reports with a total of 7 (...) patients. [ , ] Surgical procedures may require extensive planning in patients with limited skin mobility. [ ] Raynaud phenomenon Cervical sympathectomy is less beneficial for scleroderma patients than for patients with Raynaud phenomenon secondary to peripheral vascular disease. Newer surgical approaches include digital sympathectomy, with or without revision of surgically correctable vascular disease. In the event of nonhealing digital ulcers, amputation, unfortunately, sometimes is unavoidable

2014 eMedicine.com

115. Replantation (Treatment)

PM. Preoperative management of the amputated limb. Emerg Med J . 2005 Jul. 22(7):478-80. . Maricevich M, Carisen B, Mardini S, Moran S. Upper extremity and digital replantation. Hand (NY) . December 2011. 6(4):356-63. . Chai Y, Kang Q, Yang Q, Zeng B. Replantation of amputated finger composite tissues with microvascular anastomosis. Microsurgery . 2008. 28(5):314-20. . Hattori Y, Doi K, Ikeda K, Abe Y, Dhawan V. Significance of venous anastomosis in fingertip replantation. Plast Reconstr Surg (...) == processing > Replantation in Emergency Medicine Treatment & Management Updated: Sep 12, 2017 Author: Mark I Langdorf, MD, FAAEM, FACEP, MHPE, RDMS; Chief Editor: Harris Gellman, MD Share Email Print Feedback Close Sections Sections Replantation in Emergency Medicine Treatment Prehospital Care At the scene, collect and preserve all amputated parts, even those crushed and not thought to be useful. Parts not suitable for replantation can provide tendons or bone. Cool the amputated part to 4°C to preserve

2014 eMedicine Emergency Medicine

116. Iatrogenic Vascular Lesions: Surgical Perspective (Treatment)

department with signs of irreversible ischemia and extensive necrosis. Neonate boy with a high supracondilear left lower limb amputation secondary to thrombosis of the femoral artery while having an arterial line in place. Patient came to our department with signs of irreversible ischemia and extensive necrosis. Distal right foot ischemia with fingertips gangrene in a newborn babygirl with a central venous catheter in ther right femoral vein, which after multiple canulation atempts with accidental (...) the quality of limb salvage, preventing late amputation due to poor limb function. On the other hand, distal shunts have poor patency and do not improve limb salvage. [ ] (See the image below.) Neonate boy with a high supracondilear left lower limb amputation secondary to thrombosis of the femoral artery while having an arterial line in place. Patient came to our department with signs of irreversible ischemia and extensive necrosis. For carotid artery lesions, ligation of the distal internal carotid

2014 eMedicine Pediatrics

117. Iatrogenic Vascular Lesions: Surgical Perspective (Follow-up)

department with signs of irreversible ischemia and extensive necrosis. Neonate boy with a high supracondilear left lower limb amputation secondary to thrombosis of the femoral artery while having an arterial line in place. Patient came to our department with signs of irreversible ischemia and extensive necrosis. Distal right foot ischemia with fingertips gangrene in a newborn babygirl with a central venous catheter in ther right femoral vein, which after multiple canulation atempts with accidental (...) the quality of limb salvage, preventing late amputation due to poor limb function. On the other hand, distal shunts have poor patency and do not improve limb salvage. [ ] (See the image below.) Neonate boy with a high supracondilear left lower limb amputation secondary to thrombosis of the femoral artery while having an arterial line in place. Patient came to our department with signs of irreversible ischemia and extensive necrosis. For carotid artery lesions, ligation of the distal internal carotid

2014 eMedicine Pediatrics

118. Iatrogenic Vascular Lesions: Surgical Perspective (Overview)

to thrombosis of the femoral artery while having an arterial line in place. Patient came to our department with signs of irreversible ischemia and extensive necrosis. Neonate boy with a high supracondilear left lower limb amputation secondary to thrombosis of the femoral artery while having an arterial line in place. Patient came to our department with signs of irreversible ischemia and extensive necrosis. Distal right foot ischemia with fingertips gangrene in a newborn babygirl with a central venous (...) , or the child was given systemic heparin without repair, however, this expectant therapy resulted in poor limb outcomes, involving high amputation rates and diminished limb growth. Currently, aggressive surgical management yields better results, making early diagnosis and definitive repair the approach of choice at present. [ ] In children, the small size of the vessels, severe arterial vasospasm, and the consequences of diminished blood flow on limb growth must be considered. Moreover, the need for future

2014 eMedicine Pediatrics

119. Nerve Entrapment Syndromes (Treatment)

AND TREATMENT OF POSTERIOR INTEROSSEOUS NERVE ENTRAPMENT: SYSTEMATIC REVIEW. Acta Ortop Bras . 2017 Jan-Feb. 25 (1):52-54. . Clavert P, Thomazeau H. Peri-articular suprascapular neuropathy. Orthop Traumatol Surg Res . 2014 Dec. 100 (8 Suppl):S409-11. . Lanz U. Anatomical variations of the median nerve in the carpal tunnel. J Hand Surg Am . 1977 Jan. 2(1):44-53. . Wilson KE, Tat J, Keir PJ. Effects of Wrist Posture and Fingertip Force on Median Nerve Blood Flow Velocity. Biomed Res Int . 2017. 2017:7156489 (...) . . American Academy of Orthopaedic Surgeons. MANAGEMENT OF CARPAL TUNNEL SYNDROME EVIDENCE-BASED CLINICAL PRACTICE GUIDELINE. American Academy of Orthopaedic Surgeons. 2016 feb 29; Accessed: September 21, 2017. Moriarty JM, Bandyk DF, Broderick DF, Cornelius RS, Dill KE, Francois CJ, et al. ACR Appropriateness Criteria Imaging in the Diagnosis of Thoracic Outlet Syndrome. J Am Coll Radiol . 2015 May. 12 (5):438-43. . . Dellon AL. Neurosurgical prevention of ulceration and amputation by decompression

2014 eMedicine Surgery

120. Nail Pathology (Treatment)

of mind" technique. The parents should be informed that the composite tip graft either survives or dies with this technique. Convert to a full-thickness skin graft to treat the composite fingertip amputation in adults and in children older than 10 years. The tissue is defatted to the level of the dermis, and the nail bed is preserved. The distal phalanx is shortened just below the remaining pulp soft tissue, and the full-thickness graft is applied and held with a stent dressing. The tip pulp (...) obtained vascularity. Again, the judicious use of sterile matrix grafts or germinal matrix grafts offers the best reconstructive results. Hook-nail deformity A hook-nail deformity is usually the result of a fingertip amputation, with partial or complete loss of the supporting tuft of the distal phalanx and a loss of the distal nail bed and fingertip soft tissue. The regenerating nail plate follows the contour of the repaired fingertip amputation, angling in a dorsal to volar direction. Amputated

2014 eMedicine Surgery

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