Finger Soft Tissue Injuries

Detipping Injury




Distal to insertion of flexor and extensor tendons




Thick skin

- fibrofatty tissue

- fibrous septa from dermis to periosteum of skin


Nail complex


1.  Nail Plate


2.  Nail Bed

- adherent to thin periosteum of P3


A.  Proximal germinal matrix

- proximal part

- limit is semilunar lunula

- produces 90% thickness of nail plate


B.  Sterile matrix

- adherent to nail plate

- contributes little to thickness


3.  Paronychium

- surrounding skin on dorsum of fingertip


4.  Eponychium 

- covers nail plate proximally


5.  Hyponychium

- thick skin below distal edge of nail




A Oblique facing up

B Transverse

C Oblique facing down

D Oblique facing laterally


Tissue involved

- Pulp only

- Nail bed

- Bone




1.  Preserve functional length 

2.  Preserve useful sensibility

3.  Prevent Neuromas

4.  Prevent joint contractures

5.  Short morbidity with early return to work


Management Pulp Loss


Pulp loss Finger




1.  Primary healing

- best option


2.  Secondary healing

- < 1 cm2 area to cover

- 90% 5 year satisfaction


3.  Skin grafting

- 50% 5 year satisfaction

- most are painful


4.  Flaps


Local flaps / VY flaps

- Atasoy single volar

- Kutlers lateral flaps


Regional Flaps

- Cross-finger

- Thenar flap


4.  Formalisation


If bone on view and patient doesn't want flap

- take bone to level distal to extensor / flexor tendons

- remove nail bed in full (bilateral eponychial incisions)


Bone on View




1.  Shorten and cover

2.  Preserve length and flap

3.  Secondary intention

- rarely a good option except in children


Soft tissue defects Finger


Local Flaps


1.  Atasoy  VY flap



- local



- often tender and sensitive long term

- can advance only 1 cm

- suitable for defects < 1 cm



- nibble bone back

- incise skin in V

- must release all fibrous septa form distal phalanx

- attempt to leave small vessels

- check is bleeding

- if avascular is usually because have not released all fibrous septa

- leaves too much tension on vessels


2.  Kutler's bilateral VY flap


Similar concept

- on both sides of digit


3.  Modified Kleinert flap


Lateral VY flap

- based on digital pedicle

- more volar VY flap than Kutler's


Regional Flaps


de-puplped finger injury



- 2 stage procedure 

- Often result in finger stiffness

- Contra-indicated if diabetes / vascular disorders

- age relative contra-indication > 40 years


1.  Cross finger flap


Rectangle of donor skin from dorsum of P2

- Hinge is mid-axial line

- Must preserve paratenon over extensor tendon


Full-thickness skin graft to donor site from forearm

- transversely across bicipital groove

- must remove all fat from FT graft


Graft sutured 75% onto dorsum of donor finger

- flap crossed onto distal finger pulp


Divide flap under GA 3 weeks later



- Obtain 10mm 2 point discrimination of flap


2.  Thenar flap



- source of good quality skin

- very similar to finger pulp

- 2 cm defect

- IF / MF / RF

- often difficult to oppose LF


Most important point is site of flap

- Position it high and parallel to MP crease

- If low or palmar can get debilitating donor site tenderness


Make skin 1.5 x defect size to reconstruct pulp

- donor site closed primarily or FTG


3.  Abdominal Flap


Suture finger to border between chest / abdomen

- release 3 weeks later

- primary closure of chest wound


4.  Formalisation



B.  Soft Tissue Defects Thumb




1.  Moberg advancement Flap



- only for thumb

- Cover 2cm defect



- mid-axial incisions from injury site to MPJ

- entire volar skin flap with both NV bundles

- flex IPJ, suture

- can do VY at base, or transverse incision and FTG at base


2.  Cross Finger Flap from Index Finger


3.  Littler Neurovascular Island flap


Ulna side of ring or little finger

- take on just one side

- significant secondary defect

- put a skin graft into secondary defect

- rarely first choice


3.  First dorsal Metacarpal Artery Flap



- skin over dorsum of P1 of IF

- 4-sided cut and mobilise on pedicle

- With art vein and nerve

- subcutaneous tunnel


4.  Free tissue transfer of great toe pulp


5.  Abdominal Flap